The quintuple penalty of obese patients in the COVID-19 pandemic.

Since it broke out 4 months ago, the COVID-19 pandemic has strongly impacted medical practice worldwide. After spreading from China, COVID-19 has claimed an increasing number of victims among whom persons with obesity are overrepresented. We do not know whether persons with obesity are more exposed to the pandemic than others. We do know that during the H1N1 epidemic, obesity was a major risk factor for severe forms of infection needing hospitalization in intensive care or with fatal outcome [1]. The COVID-19 pandemic is following the same pattern. However, the impact of COVID-19 on persons with obesity goes further than a risk of severe forms. Adverse effects are observed even in those not infected, during hospitalization in those who are, and after discharge from hospital. The penalties that persons with obesity suffer are 5-fold.

First penalty

Noninfected persons with obesity are being confined at home during the pandemic. Hence, any planned surgery they need is deferred to some later date, with the attendant adverse psychological impact of this uncertainty. Confinement also has several harmful effects [2], including possible malnutrition, recurrence of eating disorders, stress or depression, and isolation or social exclusion.

Second penalty

Obesity is often associated with respiratory malfunction (reduced maximum expired flow volume and functional capacity, sleep apnea, and chronic obstructive pulmonary disease), and other co-morbidities, such as diabetes, cardiovascular diseases, and nonalcoholic fatty liver disease. This array of disorders, sometimes present concurrently, worsen the prognosis of patients with COVID-19 [3]. There are still no large-scale data, but it is estimated that three quarters of patients in hospital intensive care units are overweight or obese [4]. The inflammatory syndrome associated with obesity (elevated cytokine levels) and still imperfectly understood immune system disturbances also contribute to the worsened condition of patients with inflammation secondary to COVID-19 infection [5].

Third penalty

During intensive care, patients with obesity who are immobilized are exposed to the risk of rapid muscle wasting, resulting in sarcopenic obesity [6]. This new clinical condition, which is difficult to diagnose, further worsens co-morbidities, lowers capacity for prompt recovery in convalescence, and lengthens hospital stay [7]. It is therefore important not to delay nutritional support in intensive care [8].

Fourth penalty

Care given to obese patients, besides medical care, is highly specific and needs means and expertise that may be lacking in hospitals struggling with the COVID-19 pandemic [9]. The difficulties with tracheal intubation and with the necessary mobilization of obese patients, often frequent, are well-known. Beds have to support extra loads, and care equipment, such as cuffs and imaging instruments (computed tomography and medical resonance imaging), have to be adapted to patients’ girth. Last, if ventilation is performed, the supine lying position must be avoided in these patients and the prone position preferred.

Fifth penalty

If a patient’s condition improves and he or she can leave intensive care and be discharged from hospital, the question then arises of functional, nutritional, and physical rehabilitation [10] and psychological support, which may last for months [11]. This postcritical care will further delay any surgery.

Conclusion

Patents with obesity are clearly at a severe disadvantage compared with other patients affected by COVID-19. If they are not infected, they suffer harmful effects of confinement. If they are infected, they are exposed to a greater risk of admission to prolonged intensive care, with sarcopenia, care provision ill-suited to their specific needs, and possible postcritical complications. The impact of the COVID-19 pandemic in the setting of a global syndemic that includes obesity, thus deserves urgent consideration [12].