Association of obesity with severe outcomes among older and younger adult patients with COVID-19 infection: retrospective cohort study
SPMC J Health Care Serv. 2024;10(1):1 ARK: https://n2t.net/ark:/76951/jhcs583cgr
1Department of Internal Medicine, Southern Philippines Medical Center, JP Laurel Ave, Davao City, Philippines
Correspondence Donnah Bless L Mosqueda, donnahblessmd1@gmail.com
Received 24 November 2022
Accepted 16 January 2024
Cite as Mosqueda DBL. Association of obesity with severe outcomes among patients with COVID-19 infection: retrospective cohort study. SPMC J Health Care Serv. 2024;10(1):1. https://n2t.net/ark:/76951/jhcs583cgr
Introduction
Early in the COVID-19 pandemic, obesity was identified as an important risk factor for SARS-CoV-2 infection and for an increased risk of severe COVID-19.1 2 Obesity is also associated with various comorbid conditions, which are linked to increased morbidity and mortality from COVID-19.2 Furthermore, obesity can lead to respiratory compromise,3 and obese individuals have been shown to exhibit defective innate and adaptive immune responses,4 making them more susceptible to severe COVID-19. Obesity increases the risk of adverse COVID-19 outcomes, including higher rates of ICU admission, invasive mechanical ventilation, and death, especially in patients older than 65 years.5 6
The association between obesity and COVID-19 outcomes, such as an increased risk of ICU admission, critical illness, or hospital mortality, has been extensively studied in literature.5 6 7 8 9 10 11 However, these studies have not specifically investigated the association among those who are less than 60 years old. In 2021, there was a demographic shift in the COVID-19 population, with a preponderance of severe disease in younger adults.12 13 A large-scale, multi-center study exploring the association between body mass index (BMI) and COVID-19 clinical outcomes conducted among Filipinos concluded that abnormalities in BMI are associated with severe or critical COVID-19. 14 Yet this study was done among patients who had COVID-19 early in the pandemic, before COVID-19 vaccines were available. With the subsequent rollout of COVID-19 vaccinations, it becomes crucial to re-examine this association.
We did this study, during a period when COVID-19 vaccines were starting to become publicly available. Our aim was to determine the association of obesity (BMI of ≥30) with the presence of any severe clinical outcomes among patients with COVID-19. Severe clinical outcomes include high-flow oxygen administration, ICU admission, mechanical ventilation, and death. We also explored this association separately among younger adults and older adults.
Methodology
Setting
We conducted a retrospective cohort study on patients who tested positive for COVID-19 and were admitted to Southern Philippines Medical Center (SPMC). In 2021, our institution had an average monthly admission of 679 patients with COVID-19.
Participants
All discharged adult patients ≥18 years old with laboratory-confirmed diagnosis of COVID-19 by rapid polymerase chain reaction (RT-PCR) test from January 1 to September 30, 2021 were eligible for the study. However, only a sample of these eligible patients was included in the study through convenience sampling. We excluded patients with incomplete records on body weight and height.
The minimum sample size for this study was estimated using StatCalc from Epi Info™ v5.5.11. The estimation was based on the assumption that 35% of patients with a BMI of ≥30 were either admitted to the ICU and/or died,15 that the ratio of patients with a BMI of ≥30 and those with a BMI of <30 is 2.7, and that ICU admission and/or death among patients with a BMI of <30 is lower by 20% than those with a BMI of ≥30. In a computation for odds ratio to determine the association of obesity with death, carried out with 5% level of significance, a total sample size of at least 370 will have 80% power to reject the null hypothesis if the alternative holds.
Data collection
We reviewed the medical records of each patient included in the study. From these records, we collected data on age, sex, comorbidities--including hypertension, diabetes mellitus, cardiovascular disease, kidney disease, cancer, chronic obstructive pulmonary disease, bronchial asthma, pulmonary tuberculosis, and others--height, weight, and vaccination status. The main exposure variable, BMI, was computed using the formula suggested by the Centers for Disease Control and Prevention (CDC).16 We also used the World Health Organization’s (WHO) classification of weight status17 to classify patients into two groups: those with BMI of <30 and those with BMI of ≥30.
The main outcome measure of this study was the occurrence of any severe outcomes of COVID-19 during patient admission. We consider a patient to have experienced a severe outcome if they required at least one of the following treatments during admission: high-flow oxygen administration, ICU admission, mechanical ventilation, or if they died.
Statistical analysis
In this study, categorical variables are reported as frequencies and percentages, and proportions were compared using the chi-square test or Fisher's exact test. We used the Shapiro-Wilk test to check if the continuous variable (age) is normally distributed. Upon finding that age was not normally distributed we computed the medians and interquartile ranges of the variable and performed age comparison using the rank-sum test. A 0.05 two-tailed p-value was considered significant. We performed univariate logistic regression to determine the unadjusted associations of selected demographic and clinical factors with severe outcomes of COVID-19. We also performed a multivariable logistic regression to explore the association of BMI and severe COVID-19 outcomes. In this analysis model, we included only selected demographic and clinical characteristics that could potentially confound the results, and we controlled the results for these possible confounders. Additionally, we stratified the data based on age groups: younger adults (those between 18 and 60 years old) and older adults (those >60 years old). We expressed the associations of variables as odds ratios (OR) and their 95% confidence intervals. All statistical tests were conducted using Stata/BE 17.0.
Results
Of the 391 patients included in this study, 286 patients had BMI of <30 and 105 patients had BMI of ≥30. Table 1 shows the comparison of baseline demographic and clinical profiles of patients with BMI of <30 and those with BMI of ≥30. Compared to patients with BMI of <30, who had a median age of 60 years (IQR: 49 to 68), patients with BMI of ≥30 had a significantly lower median age of 52 years (IQR: 41 to 59; p<0.001). Furthermore, there was a significantly higher proportion of patients with diabetes among those with BMI of ≥30 (40/105, 38.10%) than among those with BMI of <30 (78/286, 27.27%; p=0.039). The two groups were comparable in terms of sex distribution, COVID-19 vaccination status, and frequencies of hypertension, cardiovascular disease, kidney disease, cancer, chronic obstructive pulmonary disease, bronchial asthma, pulmonary tuberculosis, and other comorbidities.
| Table 1 Baseline demographic and clinical characteristics of patients with body mass index (BMI) of <30 versus patients with BMI of ≥30. | |||
| Characteristics |
BMI of <30 (n=286) |
BMI of ≥30 (n=105) |
p-value |
|---|---|---|---|
| Age, median years (IQR) | 60 (49 to 68) | 52 (41 to 59) | <0.001* |
| Sex, frequency (%) (n=390) | 0.311 | ||
| Female | 132 (46.15) | 42 (40.38) | |
| Male | 154 (53.85) | 62 (59.62) | |
| Comorbidities, frequency (%) | |||
| Hypertension | 143 (50.00) | 51 (48.57) | 0.802 |
| Diabetes mellitus | 78 (27.27) | 40 (38.10) | 0.039* |
| Cardiovascular disease | 22 (7.69) | 4 (3.81) | 0.172 |
| Kidney disease | 33 (11.54) | 6 (5.71) | 0.089 |
| Cancer | 11 (3.86) | 4 (3.81) | 1.000† |
| Chronic obstructive pulmonary disease | 4 (1.40) | 2 (1.90) | 0.661† |
| Bronchial asthma | 19 (6.64) | 10 (9.52) | 0.335 |
| Pulmonary tuberculosis | 25 (8.74) | 4 (3.81) | 0.099 |
| Other comorbidities | 38 (13.29) | 18 (17.14) | 0.335 |
| COVID-19 vaccination status, frequency (%) | 1.000† | ||
| Not vaccinated | 2 (0.70) | 1 (0.95) | |
| Vaccinated | 284 (99.30) | 104 (99.05) | |
|
*Significant at p<0.05 †Fisher's exact test |
|||
Table 2 shows the comparison of severe outcomes of COVID-19 between patients with a BMI of <30 and those with a BMI of ≥30. The proportion of patients who had any severe outcomes was significantly higher among patients with BMI of ≥30 (67/105, 63.81%) compared to those with BMI of <30 (115/286, 40.21%; p<0.001). For specific severe outcomes, a significantly higher proportion of patients with BMI of ≥30 (37/105, 35.24%) received high-flow oxygen compared to those with BMI of <30 (65/286, 22.73%; p=0.013). Similarly, the proportion of patients who required mechanical ventilation was also significantly higher in the BMI of ≥30 (26/105, 24.76%) compared to the BMI of <30 (45/286, 15.73%; p=0.040). Both groups were comparable in terms of the outcomes of ICU admission and death.
| Table 2 Severe outcomes of COVID-19 among patients with BMI of <30 versus patients with BMI of ≥30. | |||
| Characteristics |
BMI of <30 (n=286) |
BMI of ≥30 (n=105) |
p-value |
|---|---|---|---|
| Any severe outcomes, frequency (%)* | 115 (40.21) | 67 (63.81) | <0.001† |
| High-flow oxygen administration | 65 (22.73) | 37 (35.24) | 0.013† |
| ICU admission | 84 (29.37) | 40 (38.10) | 0.100 |
| Mechanical ventilation | 45 (15.73) | 26 (24.76) | 0.040† |
| Death | 17 (5.94) | 4 (3.81) | 0.407 |
|
*Experienced at least one of the following outcomes during admission: high-flow oxygen administration, ICU admission, mechanical ventilation, and death.
†Significant at p<0.05. |
|||
Table 3 shows the distribution of severe COVID-19 outcomes across the different BMI categories. The highest proportion of patients with any severe outcomes from COVID-19 was found among those who have Obesity class III (11/12, 91.67%). In terms of specific severe outcomes, patients with Obesity class III had the highest proportion requiring high-flow oxygen administration (9/12, 75%). Patients with Obesity class II had the highest proportions of ICU admissions (8/19, 42.11%) and mechanical ventilation (6/19, 31.58%). Patients categorized as Overweight had the highest proportion of deaths (9/129, 6.98%).
| Table 3 Distribution of severe COVID-19 outcomes across BMI categories. | ||||||
| Outcomes | BMI categories | |||||
|---|---|---|---|---|---|---|
| Underweight (n=5) |
Normal (n=152) |
Overweight (n=129) |
Obesity class I (n=74) |
Obesity class II (n=19) |
Obesity class III (n=12) |
|
| No severe outcomes | 4 (80.00) | 96 (63.16) | 71 (55.04) | 31 (41.89) | 6 (31.58) | 1 (8.33) |
| Any severe outcomes | 1 (20.00) | 56 (36.84) | 58 (44.96) | 43 (58.11) | 13 (68.42) | 11 (91.67) |
| High-flow oxygen administration | 1 (20.00) | 30 (19.74) | 34 (26.36) | 23 (31.08) | 5 (26.32) | 9 (75.00) |
| ICU admission | 0 (0.00) | 40 (26.32) | 44 (34.11) | 29 (39.19) | 8 (42.11) | 3 (25.00) |
| Mechanical ventilation | 1 (20.00) | 25 (16.45) | 19 (14.73) | 18 (24.32) | 6 (31.58) | 2 (16.67) |
| Death | 1 (20.00) | 7 (4.61) | 9 (6.98) | 3 (4.05) | 1 (5.26) | 0 (0.00) |
Table 4 shows the association of BMI, demographic, and clinical characteristics with any severe outcomes of COVID-19. Patients with a BMI of ≥ 30 had significantly increased odds (OR=2.68; 95% CI 1.68 to 4.27; p<0.001) of experiencing any severe outcomes from COVID-19. Similarly, male patients also had significantly higher odds (OR=1.73; 95% CI 1.15 to 2.59; p=0.008) of having any severe outcomes. Due to sparse cells, the association between vaccination status and severe outcomes was not computed.
| Table 4 Univariate regression analysis showing the association of patient characteristics with severe COVID-19 outcomes (n=389). | |||
| Characteristics | Odds ratio (95% CI) | p-value | |
|---|---|---|---|
| BMI of ≥30 | 2.68 (1.68 to 4.27) | <0.001* | |
| Age >60 years old | 1.39 (0.93 to 2.08) | 0.109 | |
| Male | 1.73 (1.15 to 2.59) | 0.008* | |
| Hypertension | 1.24 (0.83 to 1.85) | 0.288 | |
| Diabetes mellitus | 1.33 (0.86 to 2.05) | 0.201 | |
| Cardiovascular disease | 0.69 (0.31 to 1.57) | 0.381 | |
| Kidney disease | 0.54 (0.27 to 1.08) | 0.079 | |
| Cancer | 1.74 (0.61 to 4.99) | 0.301 | |
| COPD | 5.82 (0.67 to 50.28) | 0.109 | |
| Bronchial asthma | 0.92 (0.43 to 1.96) | 0.826 | |
| Pulmonary tuberculosis | 1.24 (0.58 to 2.64) | 0.580 | |
| Others | 0.98 (0.56 to 1.73) | 0.954 | |
| *Significant at p<0.05. | |||
Table 5 shows the results of the multivariable regression analyses to investigate the association of BMI and severe outcomes of COVID-19. We determined that age, sex, history of hypertension, history of diabetes mellitus, and history of cardiovascular disease are confounders, and we fitted these variables into the final model. After controlling for the selected confounders, we found that a BMI of ≥30 significantly increased the odds of experiencing any severe outcomes (OR=3.19; 95% CI 1.93 to 5.27; p<0.001). When we stratified the data by patient age and controlled for sex, hypertension, diabetes mellitus, and cardiovascular disease, the results showed that a BMI of ≥30 significantly increased the odds of experiencing any severe outcomes among younger adults (OR=4.04; 95% CI 2.23 to 7.32; p<0.001). However, for older adults, we did not find a significant association between a BMI of ≥30 and any severe outcomes (OR=1.80; 95% CI 0.70 to 4.64; p=0.227).
| Table 5 Multivariable regression analysis showing the association of BMI and severe outcomes of COVID-19, controlling for identified confounders | |||
| Characteristics | Adjusted odds ratio (95% CI)* | p-value | |
|---|---|---|---|
| All ages (n=389) | |||
| BMI of ≥30 | 3.19 (1.93 to 5.27) | <0.001† | |
| Younger adults (n=221) | Adjusted odds ratio (95% CI)‡ | ||
| BMI of ≥30 | 4.04 (2.23 to 7.32) | <0.001† | |
| Older adults (n=-165) | Adjusted odds ratio (95% CI)‡ | ||
| BMI of ≥30 | 1.80 (0.70 to 4.64) | 0.227 | |
|
*controlling for age, sex, history of hypertension, diabetes mellitus, and cardiovascular disease. †Significant at p<0.05. ‡controlling for sex, history of hypertension, diabetes mellitus, and cardiovascular disease. |
|||
Discussion
Key results
Our study revealed that patients with COVID-19 with a BMI of ≥30 had significantly higher odds of experiencing any severe outcomes compared to those with BMI of <30. This remained true even after adjusting for factors such as age, sex, hypertension, diabetes mellitus, and cardiovascular disease. We also found that among younger adults, those with a BMI of ≥30 had significantly higher odds of experiencing any severe COVID-19 outcomes compared to those with BMI of <30.
Strengths and limitations
This study established the association of increased BMI with severe outcomes of COVID-19, including among the younger adult population (18-60 years old). However, this study has several limitations. Since we only used a review of records, residual confounders (i.e., COVID-19 severity, metabolic syndrome, stroke, and other comorbidities) that could potentially affect the estimation of the association between BMI and severe outcomes of COVID-19 may still be present. While this study explored the association of obesity with severe outcomes, the association of lower BMI (underweight) with severe outcomes could also be tested, as lower BMI can also be a risk factor for severe outcomes.
Interpretation
Advanced age has been shown to be the strongest risk factor for severe COVID-19 outcomes. During the early phase of the pandemic, the mortality rate of COVID-19 was more than 62 times higher among patients aged 65 years or older compared to those who are in the 0-54 years old age group.18 Data from the Centers for Disease Control and Prevention in the United States demonstrated that, until April 2023, 75% of those who have died from COVID-19 belonged to the age group 65 years or older.19
Obesity has also emerged as a strong risk factor for COVID-19 disease severity.1 2 14 20 21 22 The risk of severe illness from COVID-19 increases markedly as BMIs increases.6 Patients with the highest BMIs have a 33% increased risk of hospitalization and 61% increased risk of death compared to those with a healthy weight.23 Patients with Obesity class III or severe obesity demonstrated a greater risk of ICU admission1 and mortality5 compared to those who belong under Obesity class I (mild obesity) and Obesity class II (moderate obesity).24 Similarly, in our study, there was an observed increase in the occurrence of any severe COVID-19 outcomes as the BMI category increased. However, in contrast to the findings of the other studies, ICU admission occurrence was highest among patients with Obesity class II in our study.
When adjusted for age, a significant association had been observed between higher BMI and severe COVID-19 outcomes in younger individuals, especially in those with Obesity class III.25 26 One study demonstrated that individuals under 60 years old with a BMI of ≥30 were twice as likely to be admitted to the ICU compared to patients with a BMI of <30.27 Another study conducted among the Asian population found an association between a BMI of ≥25 and an increased mechanical ventilation among those <60 years old.28 These results are congruent with the findings of our study, which demonstrated that those who belong in the 18 to 60 age range had a higher risk of having any severe outcomes, compared to those who are >60 years old. Conversely, however, another study pointed out that, in the age group of ≥60 years old, mild/moderate obesity was associated with reduced mortality risk and increased length of stay in the ICU.29 A few studies suggested that age could be an effect modifier between obesity and COVID-19 mortality, which implies that there is a decrease in the effect of obesity on the severity and/or death from COVID-19 in patients with increased age.30 31 32 33
Several studies have found a significant inverse correlation between age and BMI in hospitalized patients with COVID-19, suggesting that younger patients are more likely to be obese. This obesity in younger patients may contribute to the risk of severe outcomes from the disease.34 35 The reason why obesity is associated more strongly with severe COVID-19 outcomes in younger than in older hospitalized patients is still not clear.25 SARS-CoV-2 has a high affinity for angiotensin-converting enzyme 2, which are highly expressed in the visceral and subcutaneous adipose tissues of host cells.36 37 These tissues, which serve as a reservoir for SARS-CoV-2, increase the integral viral load,38 thus aggravating the severity of COVID-19 in older patients.39 In younger obese patients, especially in those under 40 years old, an increased accumulation of ectopic and visceral fat was observed. This can be demonstrated through findings of highly significant fatty liver and epicardial adipose tissue (EAT) on computed tomography or ultrasonography. EAT is overexpressed in patients with COVID-19, and since EAT and the myocardium share the same microcirculation,40 it can be implicated in the myocardial inflammation and cardiorespiratory failure in patients with severe and critical COVID-19.41 42 43 Proposed mechanisms suggest that obesity contributes to worsened respiratory conditions in patients with COVID-19, potentially leading to mechanical ventilation and ICU admission. These mechanisms include restrictive lung physiology caused by weight excess, poor pulmonary reserve, and impaired respiratory mechanics.44 45
In our study, we found that among obese patients, the rate of diabetes was higher, and the rate of hypertension was nearly the same as in non-obese individuals. These findings are consistent with another study conducted on patients aged ≥18 years old who were hospitalized for COVID-19 early in the pandemic.25 Obesity is associated with an increased risk of hypertension and diabetes, which further exacerbates the cytokine storm and increases COVID-19 severity.46 Increased BMI and metabolic syndrome have been associated with immune dysfunction and confer a higher risk of death from COVID-19.47
Although the severity of COVID-19 is generally lower in younger populations, our study reveals an important clinical and public health implication: obesity may not protect individuals from the severe outcomes of COVID-19. Thus, younger age does not necessarily protect patients from COVID-19 complications, particularly among those who are obese.
Generalizability
In this study, we focused on adult patients who tested positive for COVID-19 and were admitted to our institution–a designated COVID-19 referral hospital–during the initial phase of vaccine distribution. It is important to note that our findings may primarily apply to patients with moderate to critical COVID-19, as our institution, SPMC, only admits patients within these severity categories. Therefore, our results may not extend to patients with mild cases of COVID-19.
Conclusion
In this retrospective cohort study among patients with COVID-19, we found that individuals with a BMI of ≥30 had increased odds of experience severe outcomes of COVID-19–such as high-flow oxygen administration, ICU admission, mechanical ventilation, and/or death–compared to those with a BMI of <30. For younger adults, the odds of having severe outcomes was also significantly higher among those with a BMI of ≥30 compared to those with a BMI of <30.
Contributors
DBLM had substantial contributions to the study design, and to the acquisition, analysis and interpretation of data. DBLM wrote the original draft and subsequent revisions, and reviewed, edited, and approved the final version of the manuscript. DBLM agreed to be accountable for all aspects of the work.
Acknowledgments
I would like to thank the Department of Internal Medicine in Southern Philippines Medical Center for providing the data used in this research report.
Ethics approval
This study was reviewed and approved by the Department of Health XI Cluster Ethics Review Committee (DOH XI CERC reference P21110901).
Reporting guideline used
Article source
Submitted
Peer review
External
Funding
Supported by personal funds of the authors
Competing interests
None declared
Access and license
This is an Open Access article licensed under the Creative Commons Attribution-NonCommercial 4.0 International License, which allows others to share and adapt the work, provided that derivative works bear appropriate citation to this original work and are not used for commercial purposes. To view a copy of this license, visit https://creativecommons.org/licenses/by-nc/4.0/.
References
1 Popkin BM, Du S, Green WD, Beck MA, Algaith T, Herbst CH, Alsukait RF, Alluhidan M, Alazemi N, Shekar M. Individuals with obesity and COVID-19: A global perspective on the epidemiology and biological relationships. Obes Rev. 2020 Nov;21(11):e13128. doi: 10.1111/obr.13128. Epub 2020 Aug 26. Erratum in: Obes Rev. 2021 Oct;22(10):e13305.
2 Albashir AAD. The potential impacts of obesity on COVID-19. Clin Med (Lond). 2020 Jul;20(4):e109-e113.
3 Parameswaran K, Todd DC, Soth M. Altered respiratory physiology in obesity. Can Respir J. 2006 May-Jun;13(4):203-10.
4 Andersen et al - Andersen CJ, Murphy KE, Fernandez ML. Impact of Obesity and Metabolic Syndrome on Immunity. Adv Nutr. 2016 Jan 15;7(1):66-75.
5 Poly TN, Islam MM, Yang HC, Lin MC, Jian WS, Hsu MH, Jack Li YC. Obesity and Mortality Among Patients Diagnosed With COVID-19: A Systematic Review and Meta-Analysis. Front Med (Lausanne). 2021 Feb 5;8:620044.
6 Kompaniyets L, Goodman AB, Belay B, Freedman DS, Sucosky MS, Lange SJ, Gundlapalli AV, Boehmer TK, Blanck HM. Body Mass Index and Risk for COVID-19-Related Hospitalization, Intensive Care Unit Admission, Invasive Mechanical Ventilation, and Death - United States, March-December 2020. MMWR Morb Mortal Wkly Rep. 2021 Mar 12;70(10):355-361.
7 Plourde G, Fournier-Ross E, Tessier-Grenier H, Mullie LA, Chassé M, Carrier FM. Association between obesity and hospital mortality in critical COVID-19: a retrospective cohort study. Int J Obes (Lond). 2021 Dec;45(12):2617-2622.
8 Ho JSY, Fernando DI, Chan MY, Sia CH. Obesity in COVID-19: A Systematic Review and Meta-analysis. Ann Acad Med Singap. 2020 Dec;49(12):996-1008.
9 Argenziano MG, Bruce SL, Slater CL, Tiao JR, Baldwin MR, Barr RG, et al. Characterization and clinical course of 1000 patients with coronavirus disease 2019 in New York: retrospective case series. BMJ. 2020 May 29;369:m1996.
10 Pettit NN, MacKenzie EL, Ridgway JP, Pursell K, Ash D, Patel B, Pho MT. Obesity is Associated with Increased Risk for Mortality Among Hospitalized Patients with COVID-19. Obesity (Silver Spring). 2020 Oct;28(10):1806-1810.
11 Bellan M, Patti G, Hayden E, Azzolina D, Pirisi M, Acquaviva A, et al. Fatality rate and predictors of mortality in an Italian cohort of hospitalized COVID-19 patients. Sci Rep. 2020 Nov 26;10(1):20731.
12 Guimarães R, Villela DAM, Xavier DR, Saldanha R, Barcellos C, de Freitas CM, Portela MC. Increasing impact of COVID-19 on young adults: evidence from hospitalisations in Brazil. Public Health. 2021 Sep;198:297-300.
13 World Health Organization - Representative Office for the Philippines. Philippines Coronavirus Disease 2019 (COVID-19) Situation Report #93. 2022 Jan 17 [cited 2024 Jan 31]. Available from: https://www.who.int/docs/default-source/wpro---documents/countries/philippines/emergencies/covid-19/who_phl_sitrep_93_covid-19.pdf?sfvrsn=8d0b3b97_5&download=true
14 Espiritu AI, Reyes NGD, Leochico CFD, Sy MCC, Villanueva Iii EQ, Anlacan VMM, Jamora RDG. Body mass index and its association with COVID-19 clinical outcomes: Findings from the Philippine CORONA study. Clin Nutr ESPEN. 2022 Jun;49:402-410.
15 Hajifathalian K, Kumar S, Newberry C, Shah S, Fortune B, Krisko T, Ortiz-Pujols S, Zhou XK, Dannenberg AJ, Kumar R, Sharaiha RZ. Obesity is Associated with Worse Outcomes in COVID-19: Analysis of Early Data from New York City. Obesity (Silver Spring). 2020 Sep;28(9):1606-1612.
16 Centers for Disease Control and Prevention. Defining Adult Overweight & Obesity. 2022 Jan 3 [cited 2024 Jan 31]. In: Centers for Disease Control and Prevention [Internet]. Georgia: Centers for Disease Control and Prevention. Available from: https://www.cdc.gov/obesity/basics/adult-defining.html.
17 World Health Organization. Obesity. [cited 31 Jan 2024]. In: World Health Organization [Internet]. Geneva: World Health Organizatio. c2024. Available from: https://www.who.int/westernpacific/health-topics/obesity?fbclid=IwAR1Sffc_EnL49WttTXZIWXrvHprpyOIjOlSK43fAEUP3cgLrSV5psTXTNvE#tab=tab_1
18 Yanez ND, Weiss NS, Romand JA, Treggiari MM. COVID-19 mortality risk for older men and women. BMC Public Health. 2020 Nov 19;20(1):1742.
19 Cennimo DJ. Coronavirus Disease 2019 (COVID-19). 2023 Jun12 [cited 2024 Jan 31]. In: Medscape. New York: Medscape. c1994-2024. Available from: https://emedicine.medscape.com/article/2500114-overview
20 Garg S, Kim L, Whitaker M, O'Halloran A, Cummings C, Holstein R, et al. Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 - COVID-NET, 14 States, March 1-30, 2020. MMWR Morb Mortal Wkly Rep. 2020 Apr 17;69(15):458-464.
21 Jordan RE, Adab P, Cheng KK. Covid-19: risk factors for severe disease and death. BMJ. 2020 Mar 26;368:m1198.
22 Jung CY, Park H, Kim DW, Lim H, Chang JH, Choi YJ, et al. Association between Body Mass Index and Risk of Coronavirus Disease 2019 (COVID-19): A Nationwide Case-control Study in South Korea. Clin Infect Dis. 2021 Oct 5;73(7):e1855-e1862.
23 Kuehn BM. More Severe Obesity Leads to More Severe COVID-19 in Study. JAMA. 2021 Apr 27;325(16):1603.
24 Morgan OW, Bramley A, Fowlkes A, Freedman DS, Taylor TH, Gargiullo P, et al. Morbid obesity as a risk factor for hospitalization and death due to 2009 pandemic influenza A(H1N1) disease. PLoS One. 2010 Mar 15;5(3):e9694.
25 Hendren NS, de Lemos JA, Ayers C, Das SR, Rao A, Carter S, et al. Association of Body Mass Index and Age With Morbidity and Mortality in Patients Hospitalized With COVID-19: Results From the American Heart Association COVID-19 Cardiovascular Disease Registry. Circulation. 2021 Jan 12;143(2):135-144.
26 Anderson MR, Geleris J, Anderson DR, Zucker J, Nobel YR, Freedberg D, et al. Body Mass Index and Risk for Intubation or Death in SARS-CoV-2 Infection : A Retrospective Cohort Study. Ann Intern Med. 2020 Nov 17;173(10):782-790.
27 Lighter J, Phillips M, Hochman S, Sterling S, Johnson D, Francois F, Stachel A. Obesity in Patients Younger Than 60 Years Is a Risk Factor for COVID-19 Hospital Admission. Clin Infect Dis. 2020 Jul 28;71(15):896-897.
28 Ong SWX, Young BE, Leo YS, Lye DC. Association of Higher Body Mass Index With Severe Coronavirus Disease 2019 (COVID-19) in Younger Patients. Clin Infect Dis. 2020 Nov 19;71(16):2300-2302.
29 Paravidino VB, Leite TH, Mediano MFF, Sichieri R, Azevedo E, Silva G, et al. Association between obesity and COVID-19 mortality and length of stay in intensive care unit patients in Brazil: a retrospective cohort study. Sci Rep. 2022 Aug 12;12(1):13737.
30 Fernández Villalobos NV, Ott JJ, Klett-Tammen CJ, Bockey A, Vanella P, Krause G, Lange B. Effect modification of the association between comorbidities and severe course of COVID-19 disease by age of study participants: a systematic review and meta-analysis. Syst Rev. 2021 Jun 30;10(1):194.
31 Sattar N, Ho FK, Gill JM, Ghouri N, Gray SR, Celis-Morales CA, et al. BMI and future risk for COVID-19 infection and death across sex, age and ethnicity: Preliminary findings from UK biobank. Diabetes Metab Syndr. 2020 Sep-Oct;14(5):1149-1151.
32 Gao M, Piernas C, Astbury NM, Hippisley-Cox J, O'Rahilly S, Aveyard P, et al. Associations between body-mass index and COVID-19 severity in 6·9 million people in England: a prospective, community-based, cohort study. Lancet Diabetes Endocrinol. 2021 Jun;9(6):350-359.
33 Discacciati MG, Siani S, Campa A, Nakaya HI. Why should obese youth be prioritized in COVID-19 vaccination programs? A nationwide retrospective study. Lancet Reg Health Am. 2022 Mar;7:100167.
34 Kass DA, Duggal P, Cingolani O. Obesity could shift severe COVID-19 disease to younger ages. Lancet. 2020 May 16;395(10236):1544-1545.
35 Bhasin A, Nam H, Yeh C, Lee J, Liebovitz D, Achenbach C. Is BMI Higher in Younger Patients with COVID-19? Association Between BMI and COVID-19 Hospitalization by Age. Obesity (Silver Spring). 2020 Oct;28(10):1811-1814.
36 Kassir R. Risk of COVID-19 for patients with obesity. Obes Rev. 2020 Jun;21(6):e13034.
37 Al-Benna S. Association of high level gene expression of ACE2 in adipose tissue with mortality of COVID-19 infection in obese patients. Obes Med. 2020 Sep;19:100283.
38 Landecho MF, Marin-Oto M, Recalde-Zamacona B, Bilbao I, Frühbeck G. Obesity as an adipose tissue dysfunction disease and a risk factor for infections - Covid-19 as a case study. Eur J Intern Med. 2021 Sep;91:3-9.
39 Dadras O, Afsahi AM, Pashaei Z, Mojdeganlou H, Karimi A, Habibi P, et al. The relationship between COVID-19 viral load and disease severity: A systematic review. Immun Inflamm Dis. 2022 Mar;10(3):e580.
40 Malavazos AE, Goldberger JJ, Iacobellis G. Does epicardial fat contribute to COVID-19 myocardial inflammation? Eur Heart J. 2020 Jun 21;41(24):2333.
41 Iacobellis G, Malavazos AE, Ferreira T. COVID-19 Rise in Younger Adults with Obesity: Visceral Adiposity Can Predict the Risk. Obesity (Silver Spring). 2020 Oct;28(10):1795.
42 Deng M, Qi Y, Deng L, Wang H, Xu Y, Li Z, et al. Obesity as a Potential Predictor of Disease Severity in Young COVID-19 Patients: A Retrospective Study. Obesity (Silver Spring). 2020 Oct;28(10):1815-1825.
43 Grodecki K, Lin A, Razipour A, Cadet S, McElhinney PA, Chan C, et al. Epicardial adipose tissue is associated with extent of pneumonia and adverse outcomes in patients with COVID-19. Metabolism. 2021 Feb;115:154436.
44 Sattar N, McInnes IB, McMurray JJV. Obesity Is a Risk Factor for Severe COVID-19 Infection: Multiple Potential Mechanisms. Circulation. 2020 Jul 7;142(1):4-6.
45 Palaiodimos L, Kokkinidis DG, Li W, Karamanis D, Ognibene J, Arora S, et al. Severe obesity, increasing age and male sex are independently associated with worse in-hospital outcomes, and higher in-hospital mortality, in a cohort of patients with COVID-19 in the Bronx, New York. Metabolism. 2020 Jul;108:154262.
46 Erener S. Diabetes, infection risk and COVID-19. Mol Metab. 2020 Sep;39:101044.
47 Wu S, Zhou K, Misra-Hebert A, Bena J, Kashyap SR. Impact of Metabolic Syndrome on Severity of COVID-19 Illness. Metab Syndr Relat Disord. 2022 May;20(4):191-198.
Copyright © 2024 DBL Mosqueda.
Published
January 31, 2024
Issue
Volume 10 Issue 1 (2024)
Section
Research
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