A systematic review and meta-analysis of obesity and COVID-19 outcomes

Specific and Non-specific Aspects and Future Challenges of ICU Care Among COVID-19 Patients with Obesity: A Narrative Review

PURPOSE OF REVIEW

Since the end of 2019, the coronavirus disease 2019 (COVID-19) pandemic has infected nearly 800 million people and caused almost seven million deaths. Obesity was quickly identified as a risk factor for severe COVID-19, ICU admission, acute respiratory distress syndrome, organ support including mechanical ventilation and prolonged length of stay. The relationship among obesity; COVID-19; and respiratory, thrombotic, and renal complications upon admission to the ICU is unclear.

RECENT FINDINGS

The predominant effect of a hyperinflammatory status or a cytokine storm has been suggested in patients with obesity, but more recent studies have challenged this hypothesis. Numerous studies have also shown increased mortality among critically ill patients with obesity and COVID-19, casting doubt on the obesity paradox, with survival advantages with overweight and mild obesity being reported in other ICU syndromes. Finally, it is now clear that the increase in the global prevalence of overweight and obesity is a major public health issue that must be accompanied by a transformation of our ICUs, both in terms of equipment and human resources. Research must also focus more on these patients to improve their care. In this review, we focused on the central role of obesity in critically ill patients during this pandemic, highlighting its specificities during their stay in the ICU, identifying the lessons we have learned, and identifying areas for future research as well as the future challenges for ICU activity.

Relationship of work-related and leisure-based screen time with obesity: a cross-sectional study on adults including older adults

PURPOSE

The relationship between screen time (ST) and obesity has been demonstrated; however, few studies have differentiated between work-related and leisure-based use in Japanese adults, including older adults. This study aimed to examine the relationship between both work-related and leisure-based ST and obesity in adults.

METHODS

This cross-sectional study was based on a questionnaire survey conducted in 2018. Overall, 9947 adults were invited; 3161 participants (31.8%) returned the questionnaire. Finally, 2488 participants (597 younger men (YM), 792 younger women (YW), 542 older men (OM), 557 older women (OW)) were included. The main exposures were work-related, leisure-based, and total ST. The outcome was obesity (body mass index ≥ 25 kg/m2). Log-binomial regression analysis was used to calculate prevalence ratios (PRs) and confidence intervals (CIs) for obesity with 1-h increments of each ST. Analyses were conducted in all participants and subgroups comprising YM, YW, OM, and OW.

RESULTS

Total ST was significantly associated with obesity in all participants (PR (95% CI) 1.07 (1.04-1.10), YM (1.05 (1.01-1.10)), OM (1.13 (1.05-1.22)), and OW (1.13 (1.02-1.26)). Work-related ST was significantly associated with obesity in all participants (1.08 (1.04-1.12)), YM (1.06 (1.00-1.12)), and OM (1.24 (1.08-1.42)). Leisure-based ST was significantly associated with obesity in all participants (1.09 (1.04-1.14)), YM (1.09 (1.00-1.18)), and YW (1.10 (1.01-1.20)).

CONCLUSION

ST is associated with obesity in Japanese adults including older adults; particularly, work-related ST is associated with obesity in men, and leisure-based ST, in younger individuals.

High risk of malnutrition among hospitalised coronavirus disease 2019 (COVID-19) patients is associated with mortality and other clinical outcomes

INTRODUCTION

Increasing evidence indicates an association between nutritional status and Coronavirus disease 2019 (COVID-19) disease severity. The aim of the study was to describe the risk of malnutrition, body mass index (BMI) and vitamin D status of hospitalised COVID-19 patients and assess whether they are associated with duration of hospital stay, intensive care unit (ICU) admission, mechanical ventilation, and mortality.

METHODS

The study is a descriptive retrospective study of 273 patients with COVID-19 admitted to Hospital from February 2020 to March 2021. Patients were screened for risk of malnutrition using a validated screening tool. BMI was calculated from height and weight. Insufficient Vitamin D status was defined as 25(OH)vitD <50 nmol/L. Logistic regression analysis was used to assess the association between indicators of nutritional status of patients with COVID-19, and outcomes such as duration of stay >7 days, ICU admission, mechanical ventilation, and mortality. Interaction between risk of malnutrition and BMI of ≥30 kg/m2 was assessed using the likelihood ratio test with hospital stay, ICU admission, mechanical ventilation, and mortality as outcomes.

RESULTS

Screening for risk of malnutrition identified 201 (74%) patients at a medium to high risk of malnutrition. Patients defined as being at a medium or high risk of malnutrition were more likely to be hospitalised for >7 days compared to those defined as low risk (OR: 10.72; 95% CI: 3.9-29.46; p < 0.001 and OR: 61.57; 95% CI: 19.48-194.62; p < 0.001, respectively). All patients who were admitted to ICU (n = 41) and required mechanical ventilation (n = 27) were defined as having medium or high risk of malnutrition. High risk of malnutrition was also associated with increased odds of mortality (OR: 8.87; 955 CI 1.08-72,96; p = 0.042). BMI of ≥30 kg/m2 (43%) and 25(OH)vitD <50 nmol/L (20%) were not associated with duration of stay >7 days or mortality, although BMI ≥30 kg/m2 was associated with increased risk of ICU admission (OR: 7.12; 95% CI: 1.59-31.94; p = 0.010) and mechanical ventilation (OR: 8.86; 95% CI: 1.12-69.87; p = 0.038). Interactions between risk of malnutrition and BMI ≥30 kg/m2 were not significant to explain the outcomes of hospital stay >7 days, ICU admission, mechanical ventilation, or mortality.

CONCLUSION

High risk of malnutrition among hospitalised COVID-19 patients was associated with longer duration of hospital stay, ICU admission, mechanical ventilation and mortality, and BMI ≥30 kg/m2 was associated with ICU admission and mechanical ventilation. Insufficient Vitamin D status was not associated with duration of hospital stay, ICU admission, mechanical ventilation, or mortality.

Mortality risk in patients with obesity and COVID-19 infection: a systematic review and meta-analysis

Obesity is a risk factor for severe respiratory diseases, including COVID-19 infection. Meta-analyses on mortality risk were inconsistent. We systematically searched 3 databases (Medline, Embase, CINAHL) and assessed the quality of studies using the Newcastle-Ottawa tool (CRD42020220140). We included 199 studies from US and Europe, with a mean age of participants 41.8-78.2 years, and a variable prevalence of metabolic co-morbidities of 20-80 %. Exceptionally, one third of the studies had a low prevalence of obesity of <20 %. Compared to patients with normal weight, those with obesity had a 34 % relative increase in the odds of mortality (p-value 0.002), with a dose-dependent relationship. Subgroup analyses showed an interaction with the country income. There was a high heterogeneity in the results, explained by clinical and methodologic variability across studies. We identified one trial only comparing mortality rate in vaccinated compared to unvaccinated patients with obesity; there was a trend for a lower mortality in the former group. Mortality risk in COVID-19 infection increases in parallel to an increase in BMI. BMI should be included in the predictive models and stratification scores used when considering mortality as an outcome in patients with COVID-19 infections. Furthermore, patients with obesity might need to be prioritized for COVID-19 vaccination.

Clinical outcomes and risk factors for SARS-CoV-2 breakthrough cases following vaccination with BNT162b2, CoronaVac, or ChAdOx1-S: A retrospective cohort study in Malaysia

Background

The SARS-CoV-2 pandemic drove global vaccination. However, breakthrough infections raised concerns about vaccine performance, leading the World Health Organization (WHO) to recommend investigations thereof. This study aimed to evaluate the clinical outcomes (time to breakthrough infection, intensive care unit [ICU] admission, and in-hospital mortality) of hospitalised patients with SARS-CoV-2 breakthrough infection. This was the primary outcome and the risk factors associated with its severity were the secondary outcomes.

Methods

This retrospective cohort study at a multispecialty tertiary hospital in Selangor, Malaysia included 200 fully adult vaccinated patients, with confirmed SARS-CoV-2 infection, admitted from September 2021 to February 2022. Participants were selected by simple random sampling. Infection severity was categorised as CAT 2-3 (mild-moderate) and 4-5 (severe-critical).

Results

The time to breakthrough infection was significantly longer for BNT162B2 recipients (128.47 ± 46.21 days) compared to CoronaVac (94.09 ± 48.71 days; P = 0.001) and ChAdOx1-S recipients (90.80 ± 37.59 days; P = 0.019). No significant associations were found between SARS-CoV-2-related ICU admission, mortality, and the vaccines. Multivariable analysis identified vaccine type, variant of concern, ethnicity, and hypertension as significant predictors of severity. BNT162b2 and ChAdOx1-S recipients had significantly (81 % and 74 %, respectively) lower odds of CAT 4-5 infection compared to CoronaVac recipients. Indian patients had a significantly (83 %) lower chance of CAT 4-5 infection compared to Malay patients. Patients with breakthrough infections during the Omicron period had a significantly (58 %) lower risk of CAT 4-5 compared to those in the Delta period. The CAT 4-5 risk was significantly (nearly threefold) higher in hypertensive patients.

Conclusion

The results support the Malaysian Ministry of Health's recommended booster three months after primary vaccination and the WHO's recommended heterologous booster following CoronaVac. Certain ethnic groups, hypertensive patients, and viral variants may require attention in future pandemics.

Nutrition and immunity: lessons from coronavirus disease-2019

This review will provide an overview of the immune system and then describe the effects of frailty, obesity, specific micronutrients and the gut microbiota on immunity and susceptibility to infection including data from the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic where relevant. A key role for the immune system is providing host defence against pathogens. Impaired immunity predisposes to infections and to more severe infections and weakens the response to vaccination. A range of nutrients, including many micronutrients, play important roles in supporting the immune system to function. The immune system can decline in later life and this is exaggerated by frailty. The immune system is also weakened with obesity, generalised undernutrition and micronutrient deficiencies, which all result in increased susceptibility to infection. Findings obtained during the SARS-CoV-2 pandemic support what was already known about the effects of ageing, frailty and obesity on immunity and susceptibility to infection. Observational studies conducted during the pandemic also support previous findings that multiple micronutrients including vitamins C, D and E, zinc and selenium and long-chain n-3 fatty acids are important for immune health, but whether these nutrients can be used to treat those already with coronavirus disease discovered in 2019 (COVID-19), particularly if already hospitalised, is uncertain from current inconsistent or scant evidence. There is gut dysbiosis in patients with COVID-19 and studies with probiotics report clinical improvements in such patients. There is an inverse association between adherence to a healthy diet and risk of SARS-CoV-2 infection and hospitalisation with COVID-19 which is consistent with the effects of individual nutrients and other dietary components. Addressing frailty, obesity and micronutrient insufficiency will be important to reduce the burden of future pandemics and nutritional considerations need to be a central part of the approach to preventing infections, optimising vaccine responses and promoting recovery from infection.

Association of body mass index with COVID-19-related neurologic sequelae: a retrospective cohort study

We sought to explore the relationship between body mass index (BMI) and neurologic outcomes following acute COVID-19 infection. We conducted a retrospective electronic medical record-based cohort study enrolling adults with laboratory-confirmed acute COVID-19 infection who presented to 1 of 12 academic and community hospitals in Southwestern Ontario, Canada between April 1, 2020 and July 31, 2021. Primary subjective (anosmia, dysgeusia, and/or headache) and objective (aseptic meningitis, ataxia, delirium, encephalopathy, encephalitis, intracranial hemorrhage, ischemic stroke, and/or seizure) composite neurologic outcomes were assessed, comparing obese and overweight individuals to those with underweight/normal BMI indices, adjusting for baseline characteristics. Secondary outcomes (severity of illness, length of hospital stay, SARS-CoV-2 viral load, mortality) were similarly analyzed. A total of 1437 enrolled individuals, of whom 307 (21%), 456 (32%), and 674 (47%) were underweight/normal, overweight, and obese, respectively. On multivariable analysis, there was no association between BMI category and the composite outcome for subjective (odds ratio [OR] 1.17, 95% CI 0.84-1.64, Bonferroni p = 1.00 for obese; OR 1.02, 95% CI 0.70-1.48; Bonferroni p = 1.00 for overweight) and objective (OR 0.74, 95% CI 0.42-1.30, p = 0.29 for obese; OR = 0.80, 95% CI 0.45-1.43, p = 0.45 for overweight) neurologic manifestations. There was no association between BMI category and any secondary outcome measure and no evidence of effect modification by age or sex. This study demonstrates the absence of an association between BMI and neurologic manifestations following acute COVID-19 illness. Prospective studies using standardized data collection tools and direct measures of body fat are warranted to obtain more valid effect estimates.

Impact of body composition on patient prognosis after SARS-Cov-2 infection

BACKGROUND

Since the first outbreak of coronavirus disease 2019 (COVID-19), it has been reported that several factors, including hypertension, type 2 diabetes mellitus, and obesity, have close relationships with a severe clinical course. However, the relationship between body composition and the prognosis of COVID-19 has not yet been fully studied.

METHODS

The present study enrolled 76 consecutive COVID-19 patients with computed tomography (CT) scans from the chest to the pelvis at admission. The patients who needed intubation and mechanical ventilation were defined as severe cases. Patients were categorized into four groups according to their body mass index (BMI). The degree of hepatic steatosis was estimated by the liver/spleen (L/S) ratio of the CT values. Visceral fat area (VFA), psoas muscle area (PMA), psoas muscle mass index (PMI), and intra-muscular adipose tissue content (IMAC) were measured by CT scan tracing. These parameters were compared between non-severe and severe cases.

RESULTS

Severe patients had significantly higher body weight, higher BMI, and greater VFA than non-severe patients. However, these parameters did not have an effect on disease mortality. Furthermore, severe cases had higher IMAC than non-severe cases in the non-obese group.

CONCLUSIONS

Our data suggest high IMAC can be a useful predictor for severe disease courses of COVID-19 in non-obese Japanese patients, however, it does not predict either disease severity in obese patients or mortality in any obesity grade.

Anthropometric Measurements and Admission Parameters as Predictors of Acute Respiratory Distress Syndrome in Hospitalized COVID-19 Patients

Aim: We aimed to single out admission predictors of acute respiratory distress syndrome (ARDS) in hospitalized COVID-19 patients and investigate the role of bioelectrical impedance (BIA) measurements in ARDS development. Method: An observational, prospective cohort study was conducted on 407 consecutive COVID-19 patients hospitalized at the University Clinical Center Kragujevac between September 2021 and March 2022. Patients were followed during the hospitalization, and ARDS was observed as a primary endpoint. Body composition was assessed using the BMI, body fat percentage (BF%), and visceral fat (VF) via BIA. Within 24 h of admission, patients were sampled for blood gas and laboratory analysis. Results: Patients with BMI above 30 kg/m², very high BF%, and/or very high VF levels were at a significantly higher risk of developing ARDS compared to nonobese patients (OR: 4.568, 8.892, and 2.448, respectively). In addition, after performing multiple regression analysis, six admission predictors of ARDS were singled out: (1) very high BF (aOR 8.059), (2) SaO₂ < 87.5 (aOR 5.120), (3) IL-6 > 59.75 (aOR 4.089), (4) low lymphocyte count (aOR 2.880), (5) female sex (aOR 2.290), and (6) age < 68.5 (aOR 1.976). Conclusion: Obesity is an important risk factor for the clinical deterioration of hospitalized COVID-19 patients. BF%, assessed through BIA measuring, was the strongest independent predictor of ARDS in hospitalized COVID-19 patients.

Risk of bias and certainty of evidence on the association between obesity and mortality in patients with SARS-COV-2: An umbrella review of meta-analyses

BACKGROUND & AIMS

This umbrella review of systematic reviews with meta-analysis (SR-MAs) aimed to evaluate the risk of bias and the certainty of the evidence of SR-MAs on the association between obesity and mortality in patients with SARS-CoV-2.

METHODS

We conducted a comprehensive literature search until April 22, 2022, in several databases and assessed the risk of bias of SR-MAs according to AMSTAR-2 and the certainty of evidence using the GRADE approach. The degree of overlap between meta-analyses was based on the corrected covered area (CCA) index. The results of each MA [relative risk (RR), hazard ratio (HR), or odds ratio (OR)] were extracted to evaluate the magnitude of the association between obesity and mortality.

RESULTS

A total of 24 SR-MAs were eligible, and the association between obesity and mortality was not statistically significant in eight (33.3%) of them, while the OR/HR/RR ranged from 1.14 to 3.52 in the other SR-MAs. The overlap was slight (CCA = 4.82%). The majority of SR-MAs presented critically low quality according to AMSTAR-2 (66.7%), and the certainty of the evidence for most of them (83.4%) was "very low".

CONCLUSIONS

Obesity was associated with an increased risk of death in patients with SARS-CoV-2 infection in most SR-MAs; however, a critical appraisal pointed to a high risk of bias, and the certainty of their evidence was not well graded. The dissemination of poor SR-MAs may limit the interpretation of findings, and we should always aspire to trustworthy scientific evidence.

PROSPERO

PROSPERO 2021 CRD42021253142.

Associations of body mass index with severe outcomes of COVID-19 among critically ill elderly patients: A prospective study

Background and Aim

Few studies assessed the associations of overweight and obesity with severe outcomes of coronavirus disease 2019 (COVID-19) among elderly patients. This study was conducted to assess overweight and obesity in relation to risk of mortality, delirium, invasive mechanical ventilation (IMV) requirement during treatment, re-hospitalization, prolonged hospitalization, and ICU admission among elderly patients with COVID-19.

Methods

This was a single-center prospective study that was done on 310 elderly patients with COVID-19 hospitalized in the intensive care unit (ICU). We collected data on demographic characteristics, laboratory parameters, nutritional status, blood pressure, comorbidities, medications, and types of mechanical ventilation at baseline. Patients were followed up during ICU admission and until 45 days after the first visit, and data on delirium incidence, mortality, need for a form of mechanical ventilation, discharge day from ICU and hospital, and re-hospitalization were recorded for each patient.

Results

During the follow-up period, we recorded 190 deaths, 217 cases of delirium, and 35 patients who required IMV during treatment. After controlling for potential confounders, a significant association was found between obesity and delirium such that obese patients with COVID-19 had a 62% higher risk of delirium compared with normal-weight patients (HR: 1.62, 95% CI: 1.02-2.57). This association was not observed for overweight. In terms of other outcomes including ICU/45-day mortality, IMV therapy during treatment, re-hospitalization, prolonged hospitalization, and ICU admission, we found no significant association with overweight and obesity either before or after controlling for potential confounders.

Conclusion

We found that obesity may be a risk factor for delirium among critically ill elderly patients with COVID-19.

Predictive capacity of COVID-19-related risk beliefs on weight management behaviors on a commercial weight loss program and speed of COVID-19 vaccination uptake: prospective cohort study

BACKGROUND

Recent work has shown that obesity may be a risk factor for severe COVID-19. However, it is unclear to what extent individuals have heard or believe this risk factor information, and how these beliefs may predict their preventive behaviors (e.g., weight management behaviors or COVID-19 preventive behaviors). Previous work has primarily looked at overall risk likelihood perceptions (i.e., not about obesity as a risk factor) within general populations of varying weight and concentrated on COVID-19-related preventive behaviors. Therefore, this prospective cohort study explored whether beliefs about obesity as a risk factor and overall risk likelihood perceptions predicted weight management and COVID-19 preventive behaviors over the next 16 weeks in individuals with obesity or overweight.

METHODS

Participants were 393 individuals in the US who joined a commercial weight management program in January, 2021. We leveraged the mobile program's automatic measurement of real-time engagement in weight management behaviors (e.g., steps taken), while surveys measured risk beliefs at baseline as well as when individuals received COVID-19 vaccination doses (asked monthly) over the next 16 weeks. Mixed effects models predicted engagement and weight loss each week for 16 weeks, while ordinal logistic regression models predicted the month that individuals got vaccinated against COVID-19.

RESULTS

We found that belief in obesity as a risk factor at baseline significantly predicted greater engagement (e.g., steps taken, foods logged) in program-measured weight management behaviors over the next 16 weeks in models adjusted for baseline BMI, age, gender, and local vaccination rates (minimally adjusted) and in models additionally adjusted for demographic factors. Belief in obesity as a risk factor at baseline also significantly predicted speed of COVID-19 vaccination uptake in minimally adjusted models but not when demographic factors were taken into account. Exposure to obesity risk factor information at baseline predicted greater engagement over 16 weeks in minimally adjusted models.

CONCLUSIONS

The results highlight the potential utility of effective education to increase individuals' belief in obesity risk factor information and ultimately promote engagement or faster vaccination. Future research should investigate to what extent the results generalize to other populations.

Global research trends on the links between insulin resistance and obesity: a visualization analysis

Background

Obesity increases the chance of developing insulin resistance. Numerous inflammatory markers have been linked to an increased risk of insulin resistance in obese individuals. Therefore, we performed a bibliometric analysis to determine global research activity and current trends in the field of obesity and insulin resistance.

Methods

Scopus was used between 2002 and 2021 to retrieve publications related to terms related to obesity and insulin resistance. Data were exported to Microsoft Excel. Additionally, we use VOSviewer software to create visualization maps that describe international collaborations and research hotspots.

Results

We identified 6626 publications, including 5754 journal articles, 498 review articles, and 109 letters to the editor. The most productive countries were the United States (n = 995, 30.11%), followed by China (n = 650, 9.81%), Italy (n = 412, 6.22%) and Spain (n = 386, 5.83%). Previously to 2012, this field was mainly focused on ‘adipocyte dysfunctions that link obesity with insulin resistance”; and ‘relationship between obesity, insulin resistance, and risk of cardiovascular disease’. ‘Supplements improve insulin sensitivity‘, and ‘obesity-induced inflammation and insulin resistance’ were found more recently (after 2014), indicating that research in this field has acquired significant interest and emphasis in recent years.

Conclusions

This is the first bibliometric study to focus on publications related to insulin resistance and obesity at the global level. Our reporting of quantifiable knowledge in this field may be useful in providing evidence and direction for future research, clinical practice, and educational initiatives.

Understanding the exceptional pre-vaccination Era East Asian COVID-19 outcomes

During the first year of the pandemic, East Asian countries have reported fewer infections, hospitalizations, and deaths from COVID-19 disease than most countries in Europe and the Americas. Our goal in this paper is to generate and evaluate hypothesis that may explain this striking fact. We consider five possible explanations: (1) population age structure (younger people tend to have less severe COVID-19 disease upon infection than older people); (2) the early adoption of lockdown strategies to control disease spread; (3) genetic differences between East Asian population and European and American populations that confer protection against COVID-19 disease; (4) seasonal and climactic contributors to COVID-19 spread; and (5) immunological differences between East Asian countries and the rest of the world. The evidence suggests that the first four hypotheses are unlikely to be important in explaining East Asian COVID-19 exceptionalism. Lockdowns, in particular, fail as an explanation because East Asian countries experienced similarly good infection outcomes despite vast differences in lockdown policies adopted by different countries to control the COVID-19 epidemic. The evidence to date is consistent with our fifth hypothesis - pre-existing immunity unique to East Asia - but there are still essential parts of this story left for scientists to check.

Handling of the Covid-19 Pandemic and Its Effects on Bariatric Surgical Practice: Analysis of GENEVA Study Database

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic led to a worldwide suspension of bariatric and metabolic surgery (BMS) services. The current study analyses data on patterns of service delivery, recovery of practices, and protective measures taken during the COVID-19 pandemic by bariatric teams.

MATERIALS AND METHODS

The current study is a subset analysis of the GENEVA study which was an international cohort study between 01/05/2020 and 31/10/2020. Data were specifically analysed regarding the timing of BMS suspension, patterns of service recovery, and precautionary measures deployed.

RESULTS

A total of 527 surgeons from 439 hospitals in 64 countries submitted data regarding their practices and handling of the pandemic. Smaller hospitals (with less than 200 beds) were able to restart BMS programmes more rapidly (time to BMS restart 60.8 ± 38.9 days) than larger institutions (over 2000 beds) (81.3 ± 30.5 days) (p = 0.032). There was a significant difference in the time interval between cessation/reduction and restart of bariatric services between government-funded practices (97.1 ± 76.2 days), combination practices (84.4 ± 47.9 days), and private practices (58.5 ± 38.3 days) (p < 0.001). Precautionary measures adopted included patient segregation, utilisation of personal protective equipment, and preoperative testing. Following service recovery, 40% of the surgeons operated with a reduced capacity. Twenty-two percent gave priority to long waiters, 15.4% gave priority to uncontrolled diabetics, and 7.6% prioritised patients requiring organ transplantation.

CONCLUSION

This study provides global, real-world data regarding the recovery of BMS services following the COVID-19 pandemic.

Cardiometabolic Risk after SARS-CoV-2 Virus Infection: A Retrospective Exploratory Analysis

OBJECTIVE

The aim of this study is to characterize the cardiometabolic risk of individuals who were infected with the SARS-CoV-2 virus and subsequently admitted to a hospital in a major city in mainland Portugal.

METHODS

This is a retrospective exploratory study using a sample of 102 patients, with data analysis including descriptive statistics, nonparametric measures of association between variables based on Spearman's rank-order correlation, a logistic regression model for predicting the likelihood that an individual might eventually pass away, and a multiple linear regression model to predict a likely increase in the number of days an infected patient remained in the hospital.

RESULTS

About 62.7% of the individuals required intensive care on the second day of hospitalization, remaining 14.2 days in the intensive care unit (ICU) on average. The likelihood that an individual might eventually pass away due to SARS-CoV-2 virus infection increases for the older than younger ones and increases even more if he/she suffers from cardiometabolic disorders such as obesity, especially cardiovascular disease. Older individuals and those with obesity and hypertension remained more days in the ICU.

CONCLUSIONS

A later age and the prevalence of cardiometabolic disorders severely affect the care pathway of individuals infected with the SARS-CoV-2 virus.

Obesity and Coronavirus Disease 2019

The coronavirus disease 2019 (COVID-19) pandemic has brought severe challenges to global public health. Many studies have shown that obesity plays a vital role in the occurrence and development of COVID-19. Obesity exacerbates COVID-19, leading to increased intensive care unit hospitalization rate, high demand for invasive mechanical ventilation, and high mortality. The mechanisms of interaction between obesity and COVID-19 involve inflammation, immune response, changes in pulmonary dynamics, disruptions of receptor ligands, and dysfunction of endothelial cells. Therefore, for obese patients with COVID-19, the degree of obesity and related comorbidities should be evaluated. Treatment methods such as administration of anticoagulants and anti-inflammatory drugs like glucocorticoids and airway management should be actively initiated. We should also pay attention to long-term prognosis and vaccine immunity and actively address the physical and psychological problems caused by longterm staying-at-home during the pandemic. The present study summarized the research to investigate the role of obesity in the incidence and progression of COVID-19 and the psychosocial impact and treatment options for obese patients with COVID-19, to guide the understanding and management of the disease.

Obesity and critical care nutrition: current practice gaps and directions for future research

Background

This review has been developed following a panel discussion with an international group of experts in the care of patients with obesity in the critical care setting and focuses on current best practices in malnutrition screening and assessment, estimation of energy needs for patients with obesity, the risks and management of sarcopenic obesity, the value of tailored nutrition recommendations, and the emerging role of immunonutrition. Patients admitted to the intensive care unit (ICU) increasingly present with overweight and obesity that require individualized nutrition considerations due to underlying comorbidities, immunological factors such as inflammation, and changes in energy expenditure and other aspects of metabolism. While research continues to accumulate, important knowledge gaps persist in recognizing and managing the complex nutritional needs in ICU patients with obesity. Available malnutrition screening and assessment tools are limited in patients with obesity due to a lack of validation and heterogeneous factors impacting nutrition status in this population. Estimations of energy and protein demands are also complex in patients with obesity and may include estimations based upon ideal, actual, or adjusted body weight. Evidence is still sparse on the role of immunonutrition in patients with obesity, but the presence of inflammation that impacts immune function may suggest a role for these nutrients in hemodynamically stable ICU patients. Educational efforts are needed for all clinicians who care for complex cases of critically ill patients with obesity, with a focus on strategies for optimal nutrition and the consideration of issues such as weight stigma and bias impacting the delivery of care.

Conclusions

Current nutritional strategies for these patients should be undertaken with a focus on individualized care that considers the whole person, including the possibility of preexisting comorbidities, altered metabolism, and chronic stigma, which may impact the provision of nutritional care. Additional research should focus on the applicability of current guidelines and evidence for nutrition therapy in populations with obesity, especially in the setting of critical illness.

Body-mass index COVID-19 severity: A systematic review of systematic reviews

Objectives

Conflicting studies have resulted in several systematic reviews and meta-analyses on the relationship between COVID-19 and body mass index (BMI).

Methods

This systematic review of systematic reviews followed an umbrella review design, and preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines; Medical literature analysis and retrieval system online (MEDLINE) and SCOPUS databases were searched for systematic reviews on the topic. A predefined screening and selection procedure was done for the retrieved results based on the population, intervention/interest, comparator, outcome, study (PICOS) framework.

Results

The search strategy yielded 6334 citations. With the predefined selection and screening process, 23 systematic reviews were retrieved for inclusion in the present study. Twenty-three (n = 23) systematic reviews met the inclusion criteria. As expected, there was overlap across the reviews in the included primary studies. Available evidence suggests that Class III obesity (morbid obesity) is strongly associated with increased mortality risk in patients with Covid-19. It is difficult to draw a firm conclusion about Class I and Class II obesity due to conflicting outcomes of metanalyses. Increased obesity was consistently associated with increased risk of invasive mechanical ventilation (IMV) in all the reviews with low to moderate heterogeneity.

Conclusions

Available evidence suggests that Class III obesity (morbid obesity) is strongly associated with increased mortality risk in patients with Covid-19. Increased BMI is positively associated with the risk of IMV and the severity of COVID- care.

Mechanical dependency of the SARS-CoV-2 virus and the renin-angiotensin-aldosterone (RAAS) axis: a possible new threat

Pathogens in our environment can act as agents capable of inflicting severe human diseases. Among them, the SARS-CoV-2 virus has recently plagued the globe and paralyzed the functioning of ordinary human life. The virus enters the cell through the angiotensin-converting enzyme-2 (ACE-2) receptor, an integral part of the renin-angiotensin system (RAAS). Reports on hypertension and its relation to the modulation of the RAAS are generating interest in the scientific community. This short review focuses on the SARS-CoV-2 infection's direct and indirect effects on our body through modulation of the RAAS axis. A patient having severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection, which causes COVID-19 relates to hypertension as a pre-existing disease or develops it in a post-COVID scenario. Several studies on how SARS-CoV-2 modulates the RAAS axis indicate that it alters our body's physiological balance. This review seeks to establish a hypothesis on the mechanical dependency of SARS-CoV-2 and RAAS modulation in the human body. This study intends to impart ideas on drug development and designing by targeting the modulation of the RAAS axis to inactivate the pathogenicity of the SARS-CoV-2 virus. A systematic hypothesis can severely attenuate the pathogenicity of the dreadful viruses of the future.

Nutritional risk, not obesity, is associated with mortality in critically ill COVID-19 patients

Background

Despite the identification of obesity as a risk factor for higher rates of hospital and Intensive Care Unit (ICU) admissions and complications due to COVID-19, the association between obesity and mortality in critically ill COVID-19 patients remains controversial, and the nutritional risk is little considered. Hence, our study sought to evaluate the association between obesity, nutritional risk, and mortality in critically ill patients diagnosed with COVID-19.

Methods

Retrospective study were condutcted including adult critically ill COVID-19 patients admitted to an ICU between April 2020 and March 2021. Clinical and laboratory data were collected from electronic medical records. Obesity was classified by body mass index ≥ 30 kg/m^2. A mNUTRIC score of ≥ 5 indicated high nutritional risk. Multiple Cox Regression was used to estimate the association between mNUTRIC, obesity, and mortality.

Results

From 71 patients aged 59 (± 15) years, 71.8 % were male. The frequencies of obesity (58.7 %) and death (49.3 %) were high, but obesity was not associated with mortality. Based on mNUTRIC, 85.9 % of patients were at high nutritional risk, presenting a higher frequency of mortality than patients at low nutritional risk (50.8 % vs 40.0 %; p = 0.014). Multiple Cox Regression showed that for each unit increase in mNUTRIC score the probability of death almost doubled, regardless of the presence of obesity (HR = 1.74; p < 0.001).

Conclusions

A higher nutritional risk was positively associated with mortality in critically ill COVID-19 patients, regardless of obesity, showing the importance of early identification of nutritional risk for appropriate nutritional interventions in this population.

Association between obesity and COVID-19 mortality and length of stay in intensive care unit patients in Brazil: a retrospective cohort study

The present study aimed to evaluate the association between obesity and COVID-19 mortality and length of stay in ICU patients, and how these associations were modified by age groups. We performed a retrospective multicenter cohort study with data obtained from a hospital-based registry. The sample consisted of 8183 ICU hospitalized patients who tested positive for SARS-CoV-2. Cox proportional models were used to evaluate the association between BMI categories and COVID-19 mortality and generalized linear models for the length of stay in the ICU. After adjusting for confounders, those in the younger group with severe obesity had an increased risk of COVID-19 mortality compared to those with normal/overweight (HR 1.27; 95% CI 1.01–1.61). An increased risk of death was also observed for patients with underweight (HR 3.74; 95% CI 1.39–10.07). For patients aged ≥ 60 year, mild/moderate obesity was associated with reduced mortality risk (HR 0.87; 95% CI 0.78–0.97). For the age group < 60 year, the length of stay in ICU for those patients with severe obesity was 35% higher compared to the normal/overweight category (e^β 1.35; 95% CI 1.21–1.51). Conversely, for the survivors in the underweight category, the length of stay in ICU was 51% lower compared to the normal/overweight group (e^β 0.49; 95% CI 0.31–0.78). In the age group ≥ 60 year, mild/moderate obesity was associated with an increased length of stay in the ICU (e^β 1.10; 95% CI 1.01–1.21), adjusting for confounders. These findings could be helpful for health professionals to identify subgroups at higher risk for worse outcomes.

Body Mass Index as a Predictor of Symptom Duration in COVID-19 Outpatients

BACKGROUND

Obesity is a risk factor for various diseases and can affect the disease course. Studies have shown detrimental effects of obesity on patients affected with SARS-CoV-2 including increased hospitalization and more severe disease. This study aims to investigate the effects of obesity on symptom duration in patients with COVID-19, and also explore the possibility of using BMI as a predictor of symptom duration in outpatient settings.

METHODS

Patients diagnosed with COVID-19 between June and October 2020, who had no other comorbidities, and were planned to receive treatment in the outpatient setting were enrolled in the study. Duration of the symptoms was determined based on participants' self-report of their symptoms. Linear regression was used to create predictive models based on participants' BMI, age, sex, disease presentation, and their self-reported symptom duration.

RESULTS

A total of 210 patients were included in the final analysis. Patients with higher BMI had significantly longer symptom duration. Linear regression models showed highest correlation between BMI and symptom duration compared to other covariates.

CONCLUSION

Low error in predictions and high coverage of data variability showed BMI can be used as a predictive factor for symptom duration in COVID-19 patients treated in outpatient settings.

Body mass index and clinical outcome of severe COVID-19 patients with acute hypoxic respiratory failure: Unravelling the “obesity paradox” phenomenon

Background and aims

Although obesity have been generally shown to be an independent risk factor for poor outcomes in COVID-19 infection, some studies demonstrate a paradoxical protective effect (“obesity paradox”). This study examines the influence of obesity categories on clinical outcomes of severe COVID-19 patients admitted to an intensive care unit with acute hypoxic respiratory failure requiring either non-invasive or invasive mechanical ventilation.

Methods

This is a single centre, retrospective study of consecutive COVID-19 patients admitted to the intensive care unit between 03/2020 to 03/2021. Patients were grouped according to the NICE Body Mass Index (BMI) category. Admission variables including age, sex, comorbidities, and ICU severity indices (APACHE-II, SOFA and PaO2/FiO2) were collected. Data were compared between BMI groups for outcomes such as need for invasive mechanical ventilation (IMV), renal replacement therapy (RRT) and 28-day and overall hospital mortality.

Results

340 patients were identified and of those 333 patients had their BMI documented. Just over half of patients (53%) had obesity. Those with extreme obesity (obesity groups II and III) were younger with fewer comorbidities, but were more hypoxaemic at presentation, than the healthy BMI group. Although non-significant, obesity groups II and III paradoxically showed a lower in-hospital mortality than the healthy weight group. However, adjusted (age, sex, APACHE-II and CCI) competing risk regression analysis showed three-times higher mortality in obese category I (sub-distribution hazard ratio = 3.32 (95% CI 1.30–8.46), p = 0.01) and a trend to higher mortality across all obesity groups compared to the healthy weight group.

Conclusions

In this cohort, those with obesity were at higher risk of mortality after adjustment for confounders. We did not identify an “obesity paradox” in this cohort. The obesity paradox may be explained by confounding factors such as younger age, fewer comorbidities, and less severe organ failures. The impact of obesity on indicators of morbidity including likelihood of requirement for organ support measures was not conclusively demonstrated and requires further scrutiny.

Exploring the Role of Krebs von den Lungen-6 in Severe to Critical COVID-19 Patients

COVID-19 encompasses a broad spectrum of clinical conditions caused by SARS-CoV-2 infection. More severe cases experience acute respiratory and/or multiorgan failure. KL-6 is a glycoprotein expressed mainly from type II alveolar cells with pro-fibrotic properties. Serum KL-6 concentrations have been found in patients with COVID-19. However, the relevance of KL-6 in patients with severe and critical COVID-19 has not been fully elucidated. Methods: Retrospective data from consecutive severe to critical COVID-19 patients were collected at UOC Clinica Pnuemologica “Vanvitelli”, A.O. dei Colli, Naples, Italy. The study included patients with a positive rhinopharyngeal swab for SARS-CoV-2 RNA with severe or critical COVID-19. Results: Among 87 patients, 24 had poor outcomes. The median KL-6 value in survivors was significantly lower when compared with dead or intubated patients (530 U/mL versus 1069 U/mL p < 0.001). KL-6 was correlated with body mass index (BMI) (r: 0.279, p: 0.009), lung ultrasound score (LUS) (r: 0.429, p < 0.001), Chung Score (r: 0.390, p < 0.001). KL-6 was associated with the risk of death or oro-tracheal intubation (IOT) after adjusting for gender, BMI, Charlson Index, Chung Score, and PaO2/FIO2 (OR 1.003 95% CI 1.001−1.004, p < 0.001). Serum KL-6 value of 968 has a sensitivity of 79.2%, specificity of 87.1%, PPV 70.4%, NPV 91.5%, AUC: O.85 for risk of death or IOT. Conclusions: The presented research highlights the relevance of serum KL-6 in severe to critical COVID-19 patients in predicting the risk of death or IOT.

The Role of Bioelectrical Impedance Analysis in Predicting COVID-19 Outcome

Background

Published data regarding the impact of obesity on COVID-19 outcomes are inconsistent. However, in most studies, body composition was assessed using body mass index (BMI) alone, thus neglecting the presence and distribution of adipose tissue. Therefore, we aimed to investigate the impact of body and visceral fat on COVID-19 outcomes.

Methods

Observational, prospective cohort study included 216 consecutive COVID-19 patients hospitalized at University Clinical Center Kragujevac (Serbia) from October to December 2021. Body composition was assessed using the BMI, body fat percentage (%BF), and visceral fat (VF) via bioelectrical impedance analysis (BIA). In addition to anthropometric measurements, variables in the research were socio-demographic and medical history data, as well as admission inflammatory biomarkers. Primary end-points were fatal outcomes and intensive care unit (ICU) admission.

Results

The overall prevalence of obesity was 39.3% according to BMI and 50.9% according to % BF, while 38.4% of patients had very high VF levels. After adjusting odds ratio values for cofounding variables and obesity-related conditions, all three anthropometric parameters were significant predictors of primary end-points. However, we note that % BF and VF, compared to BMI, were stronger predictors of both mortality (aOR 3.353, aOR 3.05, and aOR 2.387, respectively) and ICU admission [adjusted odds ratio (aOR) 7.141, aOR 3.424, and aOR 3.133, respectively].

Conclusion

Obesity is linked with COVID-19 mortality and ICU admission, with BIA measurements being stronger predictors of outcome compared to BMI use alone.

Assessment of Risk Factors Associated with COVID-19 Illness Outcomes in a Tertiary Hospital in Saudi Arabia

Introduction

The emergence of the coronavirus disease 2019 (COVID-19) pandemic has significantly impacted the globe. Understanding the association between the population’s demographical, clinical risk factors, and outcome of COVID-19 is essential for healthcare providers to develop guidelines and future care plans. This study reports all diagnosed COVID-19 and admitted to Johns Hopkins Aramco Healthcare (JHAH) for hospitalization from March to July 2020.

Methods

This is a retrospective study that presents the demographic, epidemiological, clinical, laboratory, and imaging characteristics of our patients and determines risk factors contributing to their COVID-19 outcome.

Results

The study included 656 patients (53% were male, 60% were older than 50 years of age, 87% were Saudi nationals, 5% pregnant, and 92% non-smokers patients). The source of infection was mostly unknown to the patient or healthcare provider (58%), followed by contact transmission (36%) and travel (5%). In addition, we found that the vast majority of hospitalized patients presented with symptoms (76%) with (90.4%) mild to moderate symptoms and have had stable hospital course during their hospitalization (82.1%). Over fifty percent of the patients had abnormal x-ray upon admission, (4.7%) were intubated, (20.3%) were admitted to an intensive care unit (ICU) or a step-down unit (SDU), and finally (5.3%) were deceased.

Conclusion

The majority of the patients in this study had mild disease, and their outcome was associated with some chronic diseases, most significantly hypertension. However, the study did not demonstrate a statistically significant association between smoking and obesity and COVID-19 outcomes.

Pandemic Preparedness: Maintaining Adequate Immune Fitness by Attaining a Normal, Healthy Body Weight

In addition to developing effective medicines and vaccines, pandemic preparedness also comprises general health-related, behavioral, and psychological aspects related to being more resistant in the case of future pandemics. In the context of the 2019 coronavirus (COVID-19) pandemic, recent research revealed that reduced perceived immune fitness was the best predictor of reporting more frequent and more severe COVID-19 symptoms. Up until now (June 2022), during the COVID-19 pandemic, the majority of patients who have been hospitalized were characterized as being overweight. It is therefore essential to further evaluate the relationship between body mass index (BMI) and immune fitness. This was performed by analyzing pooled data from previously published studies, conducted among N = 8586 Dutch adults. It was hypothesized that attaining a normal, healthy body weight is associated with optimal perceived immune fitness. The analysis revealed that a deviation from normal weight (i.e., having a BMI outside the range of 18.5 to 24.9 kg/m²) was associated with significantly reduced perceived immune fitness, as assessed with the immune status questionnaire and a single item perceived immune fitness scale. The effects were significant for both underweight and overweight groups and most pronounced for the obese groups. The results suggest that attaining a normal, healthy body weight might significantly contribute to maintaining adequate perceived immune fitness. Therefore, attaining a normal body weight might be an essential component of pandemic preparedness and should be supported by creating awareness and promoting the importance of regular exercise and the consumption of healthy food.

Identifying obesity and COVID-19 overlapping risk-factors: Protocol for a systematic review and meta-analysis

This systematic review main goal is to identify the common risk factors of obesity and COVID-19 overall, and highlight the ones related to urban settings specifically, using a syndemic framework. COVID-19 highlighted the interaction between infectious diseases and non-communicable diseases. We hypothesise that obesity and COVID-19 share determinants, thus our main goal is to identify the overlapping risk factors and their magnitude of association with both health outcomes. Literature search was conducted in Medline and Embase, Cochrane Library and Epistemonikos, Web of Science and Scopus, ASSIA and SocINDEX and, Google Scholar, in June 2021. Covidence will be used to conduct the title and abstract, and full-text screening, considering the following inclusion criteria: (a) study addresses both health outcomes, (b) full-length articles, (c) study focuses on humans and (d) studies in English. The exclusion criteria will be: (a) study addresses one of the outcomes in combination with other pathologies, (b) not full-length article, (c) study focuses on animals, (d) study not written in English, (e) study focuses on treatment (pharmacological or other), testing (prognostic) or specific patients with other pathologies and (f) study focussed in clinical and/or physiological mechanisms associated with obesity and/or COVID-19. The included studies will be assessed for quality using the Effective Public Health Practice Project for quantitative studies and the tool described by Hawker for qualitative studies. Qualitative results will be assessed using thematic analysis methods to synthesise findings and presented in summary tables. Quantitative results - meta-analysis - will be analysed and presented using Q test and Funnel Plot.

Suppression of Fibrinolysis and Hypercoagulability, Severity of Hypoxemia, and Mortality in COVID-19 Patients: A Retrospective Cohort Study

BACKGROUND

COVID-19 causes hypercoagulability, but the association between coagulopathy and hypoxemia in critically ill patients has not been thoroughly explored. This study hypothesized that severity of coagulopathy would be associated with acute respiratory distress syndrome severity, major thrombotic events, and mortality in patients requiring intensive care unit-level care.

METHODS

Viscoelastic testing by rotational thromboelastometry and coagulation factor biomarker analyses were performed in this prospective observational cohort study of critically ill COVID-19 patients from April 2020 to October 2020. Statistical analyses were performed to identify significant coagulopathic biomarkers such as fibrinolysis-inhibiting plasminogen activator inhibitor 1 and their associations with clinical outcomes such as mortality, extracorporeal membrane oxygenation requirement, occurrence of major thrombotic events, and severity of hypoxemia (arterial partial pressure of oxygen/fraction of inspired oxygen categorized into mild, moderate, and severe per the Berlin criteria).

RESULTS

In total, 53 of 55 (96%) of the cohort required mechanical ventilation and 9 of 55 (16%) required extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation-naïve patients demonstrated lysis indices at 30 min indicative of fibrinolytic suppression on rotational thromboelastometry. Survivors demonstrated fewer procoagulate acute phase reactants, such as microparticle-bound tissue factor levels (odds ratio, 0.14 [0.02, 0.99]; P = 0.049). Those who did not experience significant bleeding events had smaller changes in ADAMTS13 levels compared to those who did (odds ratio, 0.05 [0, 0.7]; P = 0.026). Elevations in plasminogen activator inhibitor 1 (odds ratio, 1.95 [1.21, 3.14]; P = 0.006), d-dimer (odds ratio, 3.52 [0.99, 12.48]; P = 0.05), and factor VIII (no clot, 1.15 ± 0.28 vs. clot, 1.42 ± 0.31; P = 0.003) were also demonstrated in extracorporeal membrane oxygenation-naïve patients who experienced major thrombotic events. Plasminogen activator inhibitor 1 levels were significantly elevated during periods of severe compared to mild and moderate acute respiratory distress syndrome (severe, 44.2 ± 14.9 ng/ml vs. mild, 31.8 ± 14.7 ng/ml and moderate, 33.1 ± 15.9 ng/ml; P = 0.029 and 0.039, respectively).

CONCLUSIONS

Increased inflammatory and procoagulant markers such as plasminogen activator inhibitor 1, microparticle-bound tissue factor, and von Willebrand factor levels are associated with severe hypoxemia and major thrombotic events, implicating fibrinolytic suppression in the microcirculatory system and subsequent micro- and macrovascular thrombosis in severe COVID-19.

EDITOR’S PERSPECTIVE

Comparing body mass index and obesity-related comorbidities as predictors in hospitalized COVID-19 patients

The association between body mass index (BMI) and poor COVID-19 outcomes in patients has been demonstrated across numerous studies. However, obesity-related comorbidities have also been shown to be associated with poor outcomes. The purpose of this study was to determine whether BMI or obesity-associated comorbidities contribute to elevated COVID-19 severity in non-elderly, hospitalized patients with elevated BMI (≥25 kg/m2 ). This was a single-center, retrospective cohort study of 526 hospitalized, non-elderly adult (aged 18-64) COVID-19 patients with BMI ≥25 kg/m2 in suburban New York from March 6 to May 11, 2020. The Edmonton Obesity Staging System (EOSS) was used to quantify the severity of obesity-related comorbidities. EOSS was compared with BMI in multivariable regression analyses to predict COVID-19 outcomes. We found that higher EOSS scores were associated with poor outcomes after demographic adjustment, unlike BMI. Specifically, patients with increased EOSS scores had increased odds of acute kidney injury (adjusted odds ratio [aOR] = 6.40; 95% CI 3.71-11.05), intensive care unit admission (aOR = 10.71; 95% CI 3.23-35.51), mechanical ventilation (aOR = 3.10; 95% CI 2.01-4.78) and mortality (aOR = 5.05; 95% CI 1.83-13.90). Obesity-related comorbidity burden as determined by EOSS was a better predictor of poor COVID-19 outcomes relative to BMI, suggesting that comorbidity burden may be driving risk in those hospitalized with elevated BMI.

Obesity augments the disease burden in COVID-19: Updated data from an umbrella review

The ongoing coronavirus disease 2019 (COVID-19) pandemic calls for identification of risk factors, which may help to identify people at enhanced risk for severe disease outcomes to improve treatment and, if possible, establish prophylactic measures. This study aimed to determine whether individuals with obesity compared to individuals with normal weight have an increased risk for severe COVID-19. We conducted a systematic literature search of PubMed, Embase and Cochrane Library and critically reviewed the secondary literature using AMSTAR-2. We explored 27 studies. Findings indicate that individuals with obesity (body mass index ≥ 30 kg/m² ), as compared to individuals without obesity, experience an increased risk for hospitalization (odds ratio [OR]: 1.40-2.45), admission to the intensive care unit (OR: 1.30-2.32), invasive mechanical ventilation (OR: 1.47-2.63), and the composite outcome 'severe outcome' (OR or risk ratio: 1.62-4.31). We found diverging results concerning death to COVID-19, but data trended towards increased mortality. Comparing individuals with obesity to individuals without obesity, findings suggested younger individuals (<60 years) experience a higher risk of severe disease compared to older individuals (≥60 years). Obesity augments the severity of COVID-19 including a tendency to increased mortality and, thus, contributes to an increased disease burden, especially among younger individuals.

Substance use disorders and COVID-19: An analysis of nation-wide Veterans Health Administration electronic health records

BACKGROUND

Substance use disorders (SUD) elevate the risk for COVID-19 hospitalization, but studies are inconsistent on the relationship of SUD to COVID-19 mortality.

METHODS

Veterans Health Administration (VHA) patients treated in 2019 and evaluated in 2020 for COVID-19 (n=5,556,315), of whom 62,303 (1.1%) tested positive for COVID-19 (COVID-19+). Outcomes were COVID-19+ by 11/01/20, hospitalization, ICU admission, or death within 60 days of a positive test. Main predictors were any ICD-10-CM SUDs, with substance-specific SUDs (cannabis, cocaine, opioid, stimulant, sedative) explored individually. Logistic regression produced unadjusted and covariate-adjusted odds ratios (OR; aOR).

RESULTS

Among COVID-19+ patients, 19.25% were hospitalized, 7.71% admitted to ICU, and 5.84% died. In unadjusted models, any SUD and all substance-specific SUDs except cannabis use disorder were associated with COVID-19+(ORs=1.06-1.85); adjusted models produced similar results. Any SUD and all substance-specific SUDs were associated with hospitalization (aORs: 1.24-1.91). Any SUD, cocaine and opioid disorder were associated with ICU admission in unadjusted but not adjusted models. Any SUD, cannabis, cocaine, and stimulant disorders were inversely associated with mortality in unadjusted models (OR=0.27-0.46). After adjustment, associations with mortality were no longer significant. In ad hoc analyses, adjusted odds of mortality were lower among the 49.9% of COVID-19+ patients with SUD who had SUD treatment in 2019, but not among those without such treatment.

CONCLUSIONS

In VHA patients, SUDs are associated with COVID-19 hospitalization but not COVID-19 mortality. SUD treatment may provide closer monitoring of care, ensuring that these patients received needed medical attention, enabling them to ultimately survive serious illness.

Effect of Mobility Restrictions During the Coronavirus Disease Epidemic on Body Composition and Exercise Tolerance in Patients With Obesity: Single Institutional Retrospective Cohort Study

BACKGROUND

This study investigated the effects of mobility restrictions (MRs) during the COVID-19 epidemic on physical activity, body composition, and exercise tolerance in patients with obesity.

METHODS

We analyzed data of obesity patients participating in a 6-month weight loss program in February 2020, and after, when the epidemic was considered to have had some effect on outdoor activity in Osaka, Japan (MR group). MR group patients were compared to patients with obesity attending the program in 2018 and 2019 (non-MR group) who had a similar number of months as MR group. Changes in physical activity, body composition, and exercise tolerance (O2 consumption; VO2) owing to the weight loss program were analyzed between both groups using analysis of covariance and logistic regression analysis.

RESULTS

Decreases in body fat were significantly higher in MR group than in non-MR group. However, increases in physical activity, VO2 at anaerobic threshold, and peak VO2 were significantly lower in MR group; however, increases in peak VO2 owing to the weight loss program were less likely to be achieved in MR group (odds ratio, 0.21; 95% confidence interval, 0.06-0.81).

CONCLUSION

MR during the COVID-19 epidemic may have affected the exercise tolerance of patients with obesity.

BMI, sex and outcomes in hospitalised patients in western Sweden during the COVID-19 pandemic

High body mass index (BMI) is associated with severe COVID-19 but findings regarding the need of intensive care (IC) and mortality are mixed. Using electronic health records, we identified all patients in western Sweden hospitalised with COVID-19 to evaluate 30-day mortality or assignment to IC. Adjusted logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI) for outcomes. Of totally 9761 patients, BMI was available in 7325 (75%), included in the study. There was a marked inverse association between BMI and age (underweight and normal weight patients were on average 78 and 75 years, whereas overweight and obese were 68 and 62 years). While older age, male sex and several comorbidities associated with higher mortality after multivariable adjustment, BMI did not. However, BMI ≥ 30 kg/m² (OR 1.46, 95% CI 1.21–1.75) was associated with need of IC; this association was restricted to women (BMI ≥ 30; OR 1.96 (95% CI 1.41–2.73), and not significant in men; OR 1.22 (95% CI 0.97–1.54). In this comprehensive hospital population with COVID-19, BMI was not associated with 30-day mortality risk. Among the obese, women, but not men, had a higher risk of assignment to IC.

Obesity and COVID-19 in-hospital fatality in southern Brazil: impact by age and skin color

OBJECTIVES

To estimate the relative risk (RR) of death associated with obesity, the attributable fraction in the exposed/with obesity (AF_o), and the hospitalized population attributable risk (hospitalized PAR) associated with obesity of death among all adults and among Black and non-Black adults hospitalized for severe COVID-19 in the state of Rio Grande do Sul, Brazil.

METHODS

This retrospective cohort study of prognostic factors analyzed all cases of adults hospitalized for severe COVID-19 in the state of Rio Grande do Sul, Brazil. The occurrence of obesity was measured using secondary data from hospital teams’ surveillance records. The outcome assessed was hospital deaths caused by severe COVID-19. Poisson regression was used to estimate RRs and 95% confidence intervals (95%CI).

RESULTS

The study sample consisted of 100,099 patients hospitalized for severe COVID-19, most of whom were White (84.7%) and male (54.7%). The effect of obesity was strongly modified by age, being higher in younger age groups. For the 18–39-year-old age group, RR = 2.54 (95%CI: 2.33–2.77), and in individuals 70 years and above, RR = 1.09 (95%CI: 1.05–1.13). For the 18–39-year-old age range, AF_o = 60.6% and AF_o = 42.5% in individuals 40–59 years old. For all hospitalizations, Hospitalized PAR measuring obesity for individuals 18–39 years old was 25.3%, while in the 40–59-year-old range, the hospitalized PAR = 11.2%. The hospitalized PAR was 31.7% in the Black population aged 18–39 years and 24.8% in non-Blacks. The hospitalized PAR was also larger in Blacks aged 40-59 years.

CONCLUSIONS

Obesity largely impacted in-hospital case-fatality rates among young adults and Black people contaminated by COVID-19. These data highlight the extent of the risk concerning obesity, a highly prevalent chronic condition.

Rethinking COVID-19 and Beyond: Prevention, Remedies, and Recovery

In a relatively short timeframe, millions of deaths and illnesses associated with COVID-19 have been reported, accompanied by substantial economic losses, and overall, negatively impacting society. This experience should serve as a wakeup call to those in public health and healthcare, along with politicians and citizens: COVID-19 is considered a predictable and preventable disaster. While various reactive responses to address the pandemic were implemented, some with adverse effects, proactive measures in the years before COVID-19 were neglected. Predominately this involved the development of a preventable overfat pandemic, which played a key role in both rising rates of chronic disease, the comorbidities that increase the risk for COVID-19, along with associated inflammation and malnutrition. This increased the risk of infection in billions of people worldwide, which, in essence, primed society for high rates of COVID-19 infection. Excess body fat evolves primarily from poor nutrition, particularly the overconsumption of sugar and other refined carbohydrates, which replace the vital nutrients needed for optimal immune function. Sugar and refined carbohydrates must be considered the new tobacco, as these foods are also devoid of nutrients, and underly inflammatory chronic diseases. A balanced diet of nutrient-dense wholefood must be emphasized to combat infectious and inflammatory diseases. Implementing proactive preventive lifestyle changes must begin now, starting with simple, safe, and inexpensive dietary modifications that can quickly lead to a healthier population.

Childhood obesity and risk of SARS-CoV-2 infection

Objective

To estimate the association between childhood obesity and the risk of SARS-CoV-2 infection in a cohort followed from 4 to 12 years of age.

Methods

The data were obtained from two independent sources: the Longitudinal Childhood Obesity Study (ELOIN) and the epidemiological surveillance system data from the Community of Madrid (Spain), which served to identify the population within the cohort with confirmed SARS-CoV-2 infection. The SARS-CoV-2 registry was cross-checked with the cohort population at 11–12 years of age. A total of 2018 eligible participants were identified in the cohort, who underwent physical examinations at 4, 6, and 9 years of age during which weight, height, and waist circumference were recorded. General obesity (GO) was determined according to the WHO-2007 criteria whereas abdominal obesity (AO) was defined based on the International Diabetes Federation (IDF) criteria. The relative risks (RRs) of infection were estimated using a Poisson regression model and adjusted by sociodemographic variables, physical activity, and perceived health reported by the parents.

Results

The accumulated incidence of SARS-CoV-2 infection was 8.6% (95% CI: 7.3–9.8). The estimated RR of SARS-CoV-2 infection was 2.53 (95% CI: 1.56–4.10) and 2.56 (95% CI: 1.55–4.21) for children 4–9 years old with stable GO and AO, respectively, compared with those who did not present GO.

Conclusions

Childhood obesity is an independent risk factor for SARS-CoV-2 infection. This study provides new evidence that indicates that obesity increases the vulnerability of the paediatric population to infectious diseases.

A Tale of Two Surges: Differences in Outcomes in the COVID-19 Pandemic in a Community Teaching Hospital in Massachusetts

Background

The coronavirus disease 2019 (COVID-19) pandemic has challenged the scientific community in the prompt implementation of therapies. We report and contrast characteristics and outcomes from two COVID-19 surges in March 2020 and December 2020 in patients at MetroWest Medical Center in Framingham.

Methods

The study was conducted at MetroWest Medical Center. We extracted the data of 315 patients from March 17, 2020, to June 30, 2020, and 104 patients from November 19, 2020, to December 30, 2020. All patients were inpatients and had confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by polymerase chain reaction (PCR). We extracted the patient’s demographic information, clinical data, and given treatments. We also examined comorbidities and categorized them by the Charlson Comorbidity Index (CCI). The primary endpoints were intensive care unit (ICU) level of care, mechanical ventilation, or death.

Results

A total of 419 patients were studied. The median age was 76. During the first surge (S1), 150 (47%) were from nursing homes and 133 (42%) were from independent living. More than half (72) of the independent living patients had a primary language other than English. During the second surge (S2), 12% (13) were from nursing homes. The most common comorbidities were similar for both groups and included obesity, diabetes, and chronic lung disease. However, during the first surge, 33% (104) of the patients had dementia. The median Charlson Comorbidity Index score was worse in the first surge; the predicted 10-year survival was 21% versus 53%. The treatments given included remdesivir in 5% (16) in the first surge versus 60% (62) in the second surge. Dexamethasone was given only in the second surge in 69% (72) of the patients.

Outcomes

The reported outcomes are contrasted by the first versus the second surge. Admission to the intensive care unit was required in 83 (27%) of the patients during the first surge versus 15 (14%) of the patients during the second surge. Mechanical ventilation was required in 33 (11%) of the patients during the first surge versus 5 (11%) of the patients during the second surge. The overall mortality was 25% during the first surge (79) versus 9% (9) during the second surge.

Conclusion

Among patients with COVID-19 infection admitted to a community teaching hospital during the second Massachusetts surge, there was a significant improvement in clinical outcomes, particularly mortality, compared with patients admitted during the early pandemic. It is tempting to attribute the improved outcomes to the implementation of treatment with corticosteroids and more use of antiviral therapy. However, the patients admitted during the larger first surge were more likely to have a do not resuscitate (DNR) status on admission, be from a nursing home, have dementia, and have poorer predicted survival.

The effect of obesity on in-hospital mortality among patients with COVID-19 receiving corticosteroids

BACKGROUND AND AIMS

Obesity has been reported to be one of the most frequent comorbidities in COVID-19 patients and associated with higher rates of in-hospital mortality compared to non-obese patients. Acute kidney injury (AKI) is also known to be a complication associated with obesity in critically-ill COVID-19 patients. We aimed to investigate whether obesity was associated with increased risk of in-hospital mortality and AKI among patients with COVID-19 treated with corticosteroids.

METHODS

We utilized 9965 hospitalized COVID-19 patient data and divided patients who were treated with corticosteroids into 6 groups by body mass index (BMI) (less than 18.5, 18.5-25, 25-30, 30-35, 35-40, 40 kg/m² or greater). The association between BMI and in-hospital mortality and between BMI and incidence rate of AKI during admission among COVID-19 patients receiving corticosteroids were retrospectively investigated.

RESULTS

There were 4587 study participants receiving corticosteroids (mean age 66.5 ± 15.5 years, men 56.6%, mean BMI 29.0 ± 7.2 kg/m²). The smooth spline curve suggested a J-shape association between BMI and in-hospital mortality. Patients with BMI above 40 kg/m² exhibited a higher in-hospital mortality and higher incidence rate of AKI during admission compared to patients with BMI between 25 and 30 kg/m². The differences in in-hospital mortality and the rate of AKI were larger among patients with severe COVID-19.

CONCLUSIONS

Class III obesity was associated with high in-hospital mortality and AKI in patients with COVID-19 treated by corticosteroids. Clinicians must stay vigilant on the impact of class III obesity and development of AKI to disease trajectory of COVID-19 patients.

Imaging of COVID-19

The novel coronavirus disease 2019 (COVID-19) emerged as the source of a global pandemic in late 2019 and early 2020 and quickly spread throughout the world becoming one of the worst pandemics in recent history. This chapter reviews the most up to date radiological literature and outlines the utility of thoracic imaging in COVID-19, defining both the common and the less typical imaging appearances during the acute and subacute phases of COVID-19. The short term complications and the long term sequela will also be discussed in the context of radiology, including pulmonary emboli, acute respiratory distress syndrome, superimposed infections, barotrauma, cardiac manifestations, pulmonary parenchymal scarring and fibrosis.

Association Between Obesity and COVID-19 Disease Severity in Saudi Population

BACKGROUND

The persistent coronavirus disease 2019 (COVID-19) outbreak has placed a significant burden on the scientific and medical professions. The study examined the association between body mass index (BMI), stratified by category, and severe form of COVID-19, and to explore the influence of demographic characteristics and other known risk factors.

METHODS

This was a retrospective analysis based on COVID-19 data from the Saudi Arabian Ministry of Health. Data were collected for all patients admitted to three main hospitals in Riyadh region between March 1st and July 30, 2020. The effects of BMI, demographic characteristics, clinical presentation, and comorbidities on infection severity were investigated.

RESULTS

A total of 950 patients were included in the study (70% male, 85% aged younger than 60 years old). A total of 55 (5.8%) patients were underweight, 263 (27.7%) were normal weight, 351 (37%) were overweight, 161 (17%) were obese class I, 76 (8%) were obese class II, and 44 (4.6%) were obese class III. Cough, fever, and shortness of breath were the most common symptoms among overweight patients. According to the findings of a bivariate logistic regression study, class III obesity was significantly associated with a more severe form of COVID-19 (odds ratio, 2.874; 95% confidence interval, 1.344-6.149).

CONCLUSION

This study revealed that patients with a BMI ≥40 kg/m² had a higher risk of severe COVID-19 than those with normal weight. This suggests that obesity is a risk factor for severe COVID-19 and influences disease presentation.

Risk factors for COVID-19 case fatality rate in people with type 1 and type 2 diabetes mellitus: A nationwide retrospective cohort study of 235,248 patients in the Russian Federation

THE AIM

To study the association of demographic, clinical, and laboratory factors and the use of glucose-lowering drugs and anti-coronavirus disease (COVID-19) vaccination with the COVID-19-related case fatality rate (CFR) in diabetes mellitus (DM) patients.

METHODS

This study is a nationwide observational cohort study based on the data from the National Diabetes Register (NDR) that is the database containing online clinical information about the population with DM. The outcomes (death or recovery) for COVID-19 were registered in 235,248 patients with DM [type 1 diabetes mellitus (T1DM), n = 11,058; type 2 diabetes mellitus (T2DM), n = 224,190] from March 20, 2020, until November 25, 2021. The unadjusted odds ratio (OR) and 95% confidence interval (CI) were used to estimate the risk factors for CFR. Then the ranging of significant factors was performed and the most vulnerable groups of factors for the lethal outcome were chosen.

RESULTS

The CFR due to COVID-19 was 8.1% in T1DM and 15.3% in T2DM. Increased CFR was associated with the male population [OR = 1.25 (95% CI: 1.09-1.44) in T1DM and 1.18 (95% CI: 1.15-1.21) in T2DM], age ≥65 years [OR = 4.44 (95% CI: 3.75-5.24) in T1DM and 3.18 (95% CI: 3.09-3.26) in T2DM], DM duration ≥10 years [OR = 2.46 (95% CI: 2.06-2.95) in T1DM and 2.11 (95% CI: 2.06-2.16) in T2DM], body mass index (BMI) ≥30 kg/m² [OR = 1.95 (95% CI: 1.52-2.50)] in T1DM, HbA1c ≥7% [OR = 1.35 (95% CI: 1.29-1.43)] in T2DM. The atherosclerotic cardiovascular disease (ASCVD) and chronic kidney disease (CKD) were associated with higher CFR in T1DM but not in T2DM. The pre-COVID-19 glucose-lowering therapy in T2DM was differently associated with CFR (OR): 0.61 (95% CI: 0.59-0.62) for metformin, 0.59 (95% CI: 0.57-0.61) for dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors), 0.46 (95% CI: 0.44-0.49) for sodium-glucose co-transporter-2 (SGLT2) inhibitors, 0.38 (95% CI: 0.29-0.51) for glucagon-like peptide-1 receptor agonists (arGLP-1), 1.34 (95% CI: 1.31-1.37) for sulfonylurea (SU), and 1.47 (95% CI: 1.43-1.51) for insulin. Anti-COVID-19 vaccination was associated with a lower fatality risk in both DM types: OR = 0.07 (95% CI: 0.03-0.20) in T1DM and OR = 0.19 (95% CI: 0.17-0.22) in T2DM.

CONCLUSIONS

The results of our study suggest that increased COVID-19-related fatality risk in both T1DM and T2DM patients associated with the male population, older age, longer DM duration, and absence of anti-COVID-19 vaccination. In T2DM, pre-COVID-19 glucose-lowering therapy with metformin, DPP-4 inhibitors, SGLT2 inhibitors, and arGLP-1 had a positive effect on the risk of death. The most vulnerable combination of risk factors for lethal outcome in both DM types was vaccine absence + age ≥65 years + DM duration ≥10 years.

Impact of SARS-CoV-2 Infection Among Non-Invasive Ventilated ALS Patients

BACKGROUND

The impact of SARS-CoV-2 infection among neuromuscular diseases with respiratory involvement, including amyotrophic lateral sclerosis (ALS), is still to be elucidated.

OBJECTIVES

We aim to characterize the clinical outcome of ALS patients non-invasive ventilated (NIV), following SARS-CoV-2 infection.

METHODS

We analyzed retrospectively our patients followed regularly at our ALS clinic, from the beginning of the COVID-19 pandemic (middle March 2020) to March 2021. We included patients on NIV with a documented SARS-CoV-2 infection. We recorded demographic and clinical data, including from the acute infectious illness.

RESULTS

Three men with spinal-onset ALS are described, mean age of onset was 55±9.1 years (45-61), and mean disease duration was 17.5±15.9 months (6.1-41). All of them were wheelchair-bounded, with a mean ALSFRS-R of 15.3±0.6 (15-16). One patient used NIV 15 hours/day, 2 between 4 to 7 hours/day, and all used assisted coughing twice daily. None had coexistent comorbidities. They were managed for SARS-CoV-2 infection as outpatients with fluticasone, bronchodilators, azithromycin and increasing frequency of assisted coughing. Supplemental oxygen (mean of 2 liters per minute) was needed in two patients, and one required NIV also during the daytime. Total recovery from SARS-CoV-2 infection was observed in all, despite being in an advanced stage of their disease, with severe respiratory involvement.

CONCLUSIONS

Prompt medical treatment is recommended for ALS patients with severe disease infected by SARS-CoV-2.

Safety of Bariatric Surgery During the Opening Phase After the First Wave of the COVID-19 Pandemic: Experience at an Academic Center

INTRODUCTION

Increased morbimortality in patients with COVID-19 infection who had undergone surgery has raised concerns about bariatric surgery safety during the current COVID-19 pandemic. Currently, there is scarce literature on safety outcomes after bariatric surgery during the COVID-19 pandemic.

OBJECTIVES

To determine the risk of symptomatic COVID-19 infection and associated complications during the first 30 days after bariatric surgery.

MATERIALS AND METHODS

Prospective observational cohort study including all patients who consecutively underwent primary bariatric surgery between August and December 2020.

RESULTS

A total of 189 patients were included. Median age and BMI were 36 (17-70) years and 38 (35-41) kg/m2, respectively. Forty percent of patients were women (n = 76), 59.3% (n = 112) underwent sleeve gastrectomy (SG), and 40.7% (n = 77) underwent Roux-en-Y gastric bypass (RYGB). All surgeries were performed laparoscopically. The median length of postoperative stay was 2 (0-5) days. Postoperative COVID-19 infection was detected in two patients (1.1%): one patient was readmitted without the need of intermediate or ICU care, and the other was managed as an outpatient. Major complications occurred in three patients (1.6%); none of them was COVID-19 related. Two patients required an unplanned reoperation. No patient required intermediate or ICU care, no severe COVID-19 complications were observed, and no mortality was reported.

CONCLUSION

Bariatric surgery can be safely performed during the ongoing pandemic, albeit a low risk of COVID-19 symptomatic infection. Rigorous perioperative COVID-19 institutional protocols are required to perform bariatric surgery safely during the current pandemic.

Explaining the unexpected COVID-19 trends and potential impact across Africa

Official COVID-19 case counts and mortality rates across Africa are lower than had been anticipated. Research reports, however, indicate far higher exposure rates than the official counts in some countries. Particularly in Western and Central Africa, where mortality rates are disproportionately lower than the rest of the continent, this occurrence may be due to immune response adaptations resulting from (1) frequent exposure to certain pro-inflammatory pathogens, and (2) a prevalence of low-grade inflammation coupled with peculiar modifications to the immune response based on one's immunobiography. We suggest that the two factors lead to a situation where post infection, there is a rapid ramp-up of innate immune responses, enough to induce effective defense and protection against plethora pathogens. Alongside current efforts at procuring and distributing vaccines, we draw attention to the need for work towards appreciating the impact of the apparently widespread, asymptomatic SARS-CoV-2 infections on Africa's populations vis a vis systemic inflammation status and long-term consequences for public health.

COVID-19 infection and body weight: A deleterious liaison in a J-curve relationship

During the course of the COVID-19 pandemic, obesity has been shown to be an independent risk factor for high morbidity and mortality. Obesity confers poor outcomes in younger (<60 years) patients, an age-group considered low-risk for complications, a privilege that is negated by obesity. Findings are consistent, the higher the body mass index (BMI) the worse the outcomes. Ectopic (visceral) obesity also promotes proinflammatory, prothrombotic, and vasoconstrictive states, thus enhancing the deleterious effects of COVID-19 disease. Less, albeit robust, evidence also exists for a higher risk of COVID-19 infection incurred with underweight. Thus, the relationship of COVID-19 and BMI has a J-curve pattern, where patients with both overweight/obesity and underweight are more susceptible to the ailments of COVID-19. The pathophysiology underlying this link is multifactorial, mostly relating to the inflammatory state characterizing obesity, the impaired immune response to infectious agents coupled with increased viral load, the overexpression in adipose tissue of the receptors and proteases for viral entry, an increased sympathetic activity, limited cardiorespiratory reserve, a prothrombotic milieu, and the associated comorbidities. All these issues are herein reviewed, the results of large studies and meta-analyses are tabulated and the pathogenetic mechanisms and the BMI relationship with COVID-19 are pictorially illustrated.