Contrary to earlier reports on COVID-19 and obesity, a new, peer-viewed metanalysis published in the journal Nature has concluded the obese are no more likely to die from the pandemic disease than anyone else.
That should come as good news for the more than 42 percent of Americans the Centers for Disease Control and Prevention (CDC) report to be suffering from obesity, which the federal agency calls “a common, serious, and costly disease.”
The bad news for those suffering from obesity is that, on average, they get sicker with COVID-19, spend more time in hospitals, and place a greater burden on the health care system.
The metanalysis concluded that obese people infected with the SARS-CoV-2 virus are about three times as likely to develop severe COVID-19, about three times as likely to have it progress to acute respiratory distress syndrome, 1.35 times more likely to end up in an intensive care unit, and 1.76 times more likely to end up on a ventilator.
Their likelihood of death, however – based on data from the first six months of the pandemic – was the same as for the non-obese, although there was a big caveat attached to the peer-reviewed metanalysis of 22 studies from seven different countries.
“Our data are restricted to the first six months of the pandemic and therefore represent only the first datasets published on mortality in obese and non-obese patients,” the authors wrote. “Subsequently, there have been several large cohort studies that have identified an increased risk in mortality in obese patients infected with SARS-CoV-2, and these studies and likely other relevant studies were not included in our meta-analyses because of the cut-off date for our search.
“In addition, there are several meta-analyses with later search dates than ours which do show an increased risk of mortality in obese COVID-19 patients.”
A matter of timing?
One of those latter studies concluded the risk of death is more than double for the obese. The authors of the Nature study said their data could not refute that conclusion, but noted there is a possible explanation for fewer than expected numbers of COVID-19 deaths among the seriously ill obese.
“Obesity was associated with more severe disease but improved survival for viral pneumonias (not COVID-19),” they wrote, “a phenomenon known as the obesity paradox, and there is little known about this phenomenon.
Determining causes of death has also proven tricky in COVID-19 cases given that many of the disease’s victims were battling other medical problems before being infected. Italian authorities who analyzed that country’s data reported 89 percent of COVID-19 related deaths in that country were directly linked to SARS-CoV-2 infections – SARS-CoV-2 being the pathogen that causes COVID-19.
But for those under age 50, the Italians concluded, the cause of death for 18 percent of the people infected with SARS-CoV-2 was something other than COVID-19, and in the vast majority of cases, deaths were complicated by the fact the people who died were suffering from more than COVID-19.
“In 71.8 percent of deaths of people with a positive test to SARS-CoV-2, there is at least an extra cause contributing to death besides COVID-19: in 31.3 percent there is only one coexisting cause, in 26.8 percent there are two and in 13.7 percent there are three or more,” the Italians reported.
The Italians did not find obesity a significant complication for those over age 60, but identified it as a factor in 15 percent of the deaths of people under that age and more than 20 percent of the deaths of those under 50. Those under age 50 are generally considered the least vulnerable to COVID-19.
“It is not yet known why obese patients develop more severe COVID-19,” the authors of the Nature study wrote. “One possible explanation is that obese patients express higher levels of viral entry factors. Supporting this idea are studies indicating that obesity is associated with increased expression of ACE2, a receptor for SARS-CoV-2 that is required for viral entry” in the lungs.
“These observations suggest that obese patients may have increased susceptibility to SARS-CoV-2 infection,” the study said. “Another possible explanation is that obese patients exhibit chronic pulmonary inflammation, which has previously been linked to an increased risk of developing inflammatory lung diseases and more severe viral pneumonia. A third reason that obese patients might exhibit more severe COVID-19 is the effect of obesity on pulmonary mechanics and lung function.”
The late data on the dangerous link between obesity and COVID-19 comes at a time when Shimano, the globe’s largest bicycle parts company, has begun promoting a slick, new, obesity acceptance video that has been well received by the cycling community.
In it, one of the two, very personable cyclists who are featured say “it doesn’t matter what size you are,” and on a companion blog, the two argue for the elimination of the words “obese,” “obesity” and “overweight.”
Overweight, they write, “implies that there is an ideal weight and that one can either be over or under.” Obese and obesity are objectionable because of their Latin root, “obesus, which literally means ‘having eaten oneself fat,’ which inherently blames fat people for their bodies.”
No one should be shamed for their body type or, for that matter, their appearance, lack of intelligence, speech impediments or any other traits. But the Western World has for decades been facing an obesity epidemic in which it is well documented that size matters when it comes to health, and COVID-19 has underlined that issue.
In fact, one of the biggest takeaways from the pandemic is clearly that size matters and appears to matter significantly.
No country in the world has been able to escape the pandemic, but the death rates in the skinniest countries in the world are amazingly low. The average death rate among the ten ranked lowest in the prevalence of obesity is 4.1 per 100,000 residents, according to the Worldometer counter.
The U.S. rate as of this time is 170 per 100,000. The country’s fattest state – Mississippi, according to the World Population Review – is reporting 237 deaths per 100,000. The country’s skinniest state – Colorado – has recorded 109 deaths per 100,000, or less than half as many.
The rate of obesity in Colorado is reported at 23.8 percent. The rate of obesity in Japan is reported as 4.30 percent. Japan at this time has a COVID-19 death rate of 7.3 per 100,000 – about 15 times less than that of Colorado.
Correlation is not causation. But the correlation, in this case, combined with various studies linking obesity to various cardiometabolic health issues, indicates it would be a good thing if most Western countries encouraged their citizens to start dieting.
“The worldwide prevalence of overweight and obesity has doubled since 1980 to an extent that nearly a third of the world’s population is now classified as overweight or obese,” a peer-reviewed study in the journal Metabolism warned just two years ago. “Obesity rates have increased in all ages and both sexes irrespective of geographical locality, ethnicity or socioeconomic status, although the prevalence of obesity is generally greater in older persons and women.”
Some are now paying a sizeable price, sometimes the ultimate price, for that weight gain.
Given the large number of obese in the U.S., promoting obesity acceptance is good business for Shimano. The more obese people the company can encourage to buy bikes – whether they ride them more than once or not – the more bike parts it will sell.
But as a public policy matter, wouldn’t it be better not just for the obese but for everyone to be helping the obese deal with a serious health issue?
Noting the COVID-19 pandemic, the United Kingdom last year unveiled a broad package of government programs to battle the disease including restrictions on TV and online advertising of food high in fat, sugar and salt; a ban on “buy one get one free” deals for unhealthy food, and expansion of National Health Service (NHS) programs “so more people get the support they need to lose weight,” according to the government website.
“Separately, general practitioners will also be encouraged to prescribe exercise and more social activities to help people keep fit.”
The government of the UK has taken obesity more seriously than the U.S. government.
“Obesity is one of the biggest health crises the country faces. Almost two-thirds (63 percent) of adults in England are overweight or living with obesity – and one in three children leave primary school overweight or obese, with obesity-related illnesses costing the NHS £6 billion (about $8.3 billion) a year,” the government websites says.
“The urgency of tackling the obesity time bomb has been brought to the fore by evidence of the link to an increased risk from COVID-19.
“Living with excess weight puts people at greater risk of serious illness or death from COVID-19, with risk growing substantially as body mass index (BMI) increases. Nearly 8 percent of critically ill patients with COVID-19 in intensive care units have been morbidly obese, compared with 2.9 percent of the general population.”
Morbid obesity is defined by a BMI of 35 to 40 or higher. A 5-foot, 2-inch woman weighing 192 pounds would have a BMI of 35, according to the National Heart, Lung and Blood Institute calculator; the same would apply to a 6-foot man weighing about 260 pounds.
Obesity is a tough disease to deal with on a personal level and, in some ways, an even tougher one to deal with on a social level. Various studies have concluded that stigmitizing the overweight – commonly called “fat-shaming” – often causes them to eat more.
“Rather than motivating individuals to lose weight, weight discrimination increases risk for obesity,” Florida State University researchers concluded. But no one has come up with a good and simple method to motivate people to lose weight.
The pandemic threat of severe illness or death from obesity appears to clearly have failed as an incentive. A Harris Poll conducted for the American Psychological Association reported Americans gained an average of 15 pounds during the first year of the pandemic.
The association linked the weight gains to pandemic-driven stress.
“Adults also reported unwanted changes in sleep and increased alcohol consumption,” the association said. “Two in three (67% percent) said they have been sleeping more or less than desired since the pandemic started. Nearly one in four adults (23 percent) reported drinking more alcohol to cope with their stress.”