Missed Public Health Opportunity: Fighting Pandemic by Fighting Obesity
By Joel S. Hirschhorn
Note that views expressed in this opinion article are the writer’s personal views and not necessarily those of TrialSite.
Joel S. Hirschhorn
When I read a great recent article by Dr. Marty Makary that made CDC look incompetent, I was especially attracted to this minor part of it: “It took until March 2021 for the CDC to report that 78% of Covid hospitalizations were among overweight or obese patients.”
As someone who has spent most of my waking time for the past 17 months researching the pandemic, I started to think: Why have we not seen the public health establishment mount an aggressive national campaign to get Americans to protect themselves from COVID by losing weight? Especially because weight gain during the pandemic limitations on food freedom as well as shutdowns and school closing being acknowledged as curtailing physical activity.
Would not fighting obesity qualify as a valid prevention approach to curbing the ill effects of the COVID pandemic? Could the reason for government’s lack of aggressively pursuing an anti-obesity campaign be a bias for promoting vaccines? It seems a likely explanation.
Interestingly, however, there is a body of medical literature that says vaccines generally are less effective for obese people; if true, then there is more reason to have the public health system deal more directly with obesity to curb serious impacts of COVID. New, bold public policies are needed.
What government information and research articles have to say about the obesity-COVID connection are now covered.
CDC Documents
CDC has two detailed documents on its website on this nexus, both from March 2021. The first is mostly a general article for informing the public. The second present research findings.
The first CDC publication is titled “Obesity, Race/Ethnicity, and COVID-19.” The initial headline is “Obesity Worsens Outcomes from COVID-19.” Here are some highlights from this publication.
“Having obesity increases the risk of severe illness from COVID-19. People who are overweight may also be at increased risk.
Having obesity may triple the risk of hospitalization due to a COVID-19 infection.
Obesity is linked to impaired immune function.
Obesity decreases lung capacity and reserve and can make ventilation more difficult.
A study of COVID-19 cases suggests that risks of hospitalization, intensive care unit admission, invasive mechanical ventilation, and death are higher with increasing BMI (Body Mass Index).
The increased risk for hospitalization or death was particularly pronounced in those under age 65.
More than 900,000 adult COVID-19 hospitalizations occurred in the United States between the beginning of the pandemic and November 18, 2020. Models estimate that 271,800 (30.2%) of these hospitalizations were attributed to obesity.”
How does CDC address the question of what can be done to address the obesity-COVID connection? Mostly with generalities and platitudes with the emphasis on what individuals can do. Consider this statement where the words government and public health or pandemic management do not appear:
“This will take action at the policy and systems level to ensure that obesity prevention and management starts early, and that everyone has access to good nutrition and safe places to be physically active. Policy makers and community leaders must work to ensure that their communities, environments, and systems support a healthy, active lifestyle for all.”
There is no hint of how the government is going to address the pandemic with a major commitment to use public health efforts to reduce the negative impacts of obesity.
The second CDC document is titled “Body Mass Index and Risk for COVID-19–Related Hospitalization, Intensive Care Unit Admission, Invasive Mechanical Ventilation, and Death — United States”
Here are highlights:
“Obesity increases the risk for severe COVID-19–associated illness.”
“Among 148,494 U.S. adults with COVID-19, a nonlinear relationship was found between body mass index (BMI) and COVID-19 severity, with lowest risks at BMIs near the threshold between healthy weight and overweight in most instances, then increasing with higher BMI. Overweight and obesity were risk factors for invasive mechanical ventilation. Obesity was a risk factor for hospitalization and death, particularly among adults aged <65 years.”
“What are the implications for public health practice? These findings highlight clinical and public health implications of higher BMIs, including the need for intensive management of COVID-19–associated illness, continued vaccine prioritization and masking, and policies to support healthy behaviors.”
With this statement in March 2021 the clear emphasis on vaccines soon after they began to be distributed should be noted. There is no detailed outline of a public health plan to address obesity during the pandemic.
As to medical factors this was said:
“Obesity is a recognized risk factor for severe COVID-19, possibly related to chronic inflammation that disrupts immune and thrombogenic responses to pathogens as well as to impaired lung function from excess weight. Obesity is a common metabolic disease, affecting 42.4% of U.S. adults, and is a risk factor for other chronic diseases, including type 2 diabetes, heart disease, and some cancers. The Advisory Committee on Immunization Practices considers obesity to be a high-risk medical condition for COVID-19 vaccine prioritization.”
“Using data from the Premier Healthcare Database Special COVID-19 Release (PHD-SR), CDC assessed the association between body mass index (BMI) and risk for severe COVID-19 outcomes (i.e., hospitalization, intensive care unit [ICU] or stepdown unit admission, invasive mechanical ventilation, and death).”
“Among 148,494 adults who received a COVID-19 diagnosis during an emergency department (ED) or inpatient visit at 238 U.S. hospitals during March–December 2020, 28.3% had overweight and 50.8% had obesity. Overweight and obesity were risk factors for invasive mechanical ventilation, and obesity was a risk factor for hospitalization and death, particularly among adults aged <65 years. Risks for hospitalization, ICU admission, and death were lowest among patients with BMIs of 24.2 kg/m2, 25.9 kg/m2, and 23.7 kg/m2, respectively, and then increased sharply with higher BMIs. Risk for invasive mechanical ventilation increased over the full range of BMIs, from 15 kg/m2 to 60 kg/m2. As clinicians develop care plans for COVID-19 patients, they should consider the risk for severe outcomes in patients with higher BMIs, especially for those with severe obesity. These findings highlight the clinical and public health implications of higher BMIs, including the need for intensive COVID-19 illness management as obesity severity increases, promotion of COVID-19 prevention strategies including continued vaccine prioritization and masking, and policies to ensure community access to nutrition and physical activities that promote and support a healthy BMI.”
What is clear is that CDC thinking is mostly about considering obesity in the medical management of pandemic victims, not preventing COVID serious infections in the first place by curbing obesity at the population level.
CDC emphasized the “dose-response relationship between higher BMI and risk for hospitalization, ICU admission, invasive mechanical ventilation, and death. The finding that risk for severe COVID-19–associated illness increases with higher BMI suggests that progressively intensive management of COVID-19 might be needed for patients with more severe obesity. This finding also supports the hypothesis that inflammation from excess adiposity might be a factor in the severity of COVID-19–associated illness.”
As to public policy, this conclusion by CDC again reveals the absence of actions to address obesity: “Preventing COVID-19 in adults with higher BMIs and their close contacts remains important and includes multifaceted protection measures such as masking, as well as continued vaccine prioritization and outreach for this population.”
A New York Times article on this CDC research was titled “Severe Obesity Raises Risk of Covid-19 Hospitalization and Death, Study Finds.” The major message was that “A large new study has confirmed an association between obesity and patient outcomes among people who contract the coronavirus.” The article concluded with a strong pro-vaccine bias typical of big media:
“The findings highlight the importance of carefully managing the care of patients who are severely obese and of ensuring that people who are obese have access to vaccines and other preventive measures. This just provides further evidence for the recommendation to vaccinate those with a high B.M.I. as early as feasible,” said Sara Y. Tartof, an infectious disease epidemiologist at the Department of Research & Evaluation at Kaiser Permanente, who was not involved in the study.”
There is also a May 2021 CDC document about the many health conditions making people especially vulnerable to health impacts from COVID infection. Included is this:
“Overweight (defined as a body mass index (BMI) > 25 kg/m2 but < 30 kg/m2), obesity (BMI ≥30 kg/m2 but < 40 kg/m2), or severe obesity (BMI of ≥40 kg/m2), can make you more likely to get severely ill from COVID-19. The risk of severe COVID-19 illness increases sharply with elevated BMI.”
Medical Literature
The newest research article on obesity in the pandemic appeared in June in The Lancet with the title “Associations between body-mass index and COVID-19 severity in 6·9 million people in England: a prospective, community-based, cohort study.” Here are some highlights:
“Obesity is a major risk factor for adverse outcomes after infection with SARS-CoV-2. We aimed to examine this association, including interactions with demographic and behavioural characteristics, type 2 diabetes, and other health conditions.”
“At a BMI of more than 23 kg/m2, we found a linear increase in risk of severe COVID-19 leading to admission to hospital and death, and a linear increase in admission to an ICU across the whole BMI range, which is not attributable to excess risks of related diseases. The relative risk due to increasing BMI is particularly notable people younger than 40 years and of Black ethnicity.”
“In this very large, community-based cohort study, we found that the hazard ratio of severe outcomes from COVID-19 (ie, admission to hospital, admission to ICU, or death) increase progressively above a BMI of 23 kg/m2, which is not attributable to excess risks of related diseases such as type 2 diabetes. We found that BMI is a greater risk factor for younger people (aged 20–39 years) than for older people (≥80 years), and for Black people than for White people.”
As to government actions, “the number of participants reported to have been offered referrals to weight management programmes was low and weight change was poorly recorded.”
The conclusion: “our findings highlight the need to work towards a healthy weight at a population level.” That signifies government action.
A June 2021 Canadian article looked at the obesity-pandemic nexus. Here are some highlights:
“There is no doubt that people with higher body mass index (BMI) suffer worse outcomes from COVID-19. One meta-analysis that pooled data on more than 399 000 people with COVID-19 found that those with obesity were 113% more likely to be hospitalized, 74% more likely to need intensive care and 48% more likely to die than those with lower BMIs.”
“Researchers have attributed this increased risk to a constellation of physiological factors — from weakened immune responses due to chronic inflammation, to breathing problems and other conditions that often accompany obesity, such as type 2 diabetes.”
An earlier review article in April 2021 was titled “Obesity as a Risk Factor for Severe COVID-19 and Complications: A Review.”
“A large number of patients severely ill with COVID-19 arriving at the ICU are overweight or suffer from obesity. Obesity is associated with chronic inflammation, resulting from immune cell activity in dysfunctional (visceral) adipose tissue. Of the eleven studies investigating the association between BMI and mortality in hospitalized COVID-19 patients, ten studies observed an increased mortality rate in patients that were overweight (BMI ≥ 25 to <30), or suffering from obesity (BMI ≥ 30), or severe obesity (BMI ≥ 35).”
Obesity cannot simply be defined as an excess of fat cells. Adipose tissue releases many active substances, such as adipokines and components of the RAS, all influencing the brain and metabolic- and immune system. Being obese increases the risk of SARS-CoV-2 infection and complications via several mechanisms.
“An important lesson learned from the coronavirus pandemic is the importance of a healthy lifestyle to positively influence the course of COVID-19 disease. A non-processed nutrient-rich diet, limited excessive or overly energy-rich food, sufficient and intensive exercise, sufficient sleep and avoiding chronic psycho-emotional stress are all efficient health-promoting measures in the prevention of obesity. We also advocate an integrated multidisciplinary approach in the fight against COVID-19.” Here too, no specific government programs are advocated.
Another 2021 paper was titled “Obesity and Risk of COVID-19 Infection and Severity: Available Evidence and Mechanisms.” Here is the summary:
“The coronavirus disease 2019 (COVID-19) pandemic has resulted in worldwide research efforts to recognize people at greatest risk of developing critical illness and dying. Growing numbers of reports have connected obesity to more severe COVID-19 illness and death. Although the exact mechanism by which obesity may lead to severe COVID-19 outcomes has not yet been determined, the mechanisms appear to be multifactorial. These include mechanical changes of the airways and lung parenchyma, systemic and airway inflammation, and general metabolic dysfunction that adversely affect pulmonary function and/or response to treatment. As COVID-19 continues to spread worldwide, clinicians should carefully monitor and manage obese patients for prompt and targeted treatment.” Here too, public policy is ignored.
Early in the pandemic, April 2020, this article was published by the American Heart Association; “Obesity Is a Risk Factor for Severe COVID-19 Infection.”
“Increasing numbers of reports have linked obesity to more severe COVID-19 illness and death. In a French study, the risk for invasive mechanical ventilation in patients with COVID-19 infection admitted to the intensive treatment unit was more than 7-fold higher for those with body mass index (BMI) >35 compared with BMI <25 kg/m2. Among individuals with COVID-19 who were <60 years of age in New York City, those with a BMI between 30 to 34 kg/m2 and >35 kg/m2 were 1.8 times and 3.6 times more likely to be admitted to critical care, respectively, than individuals with a BMI <30 kg/m2.”
What about public policy? “With respect to public health, it is important to communicate risks without causing anxiety. People worldwide should be encouraged to improve their lifestyle to lessen risk both in the current and subsequent waves of COVID-19. In addition to increasing activity levels, there should be improved messaging on better diet, focusing on simpler advice to help people adopt sustainable changes. This is particularly challenging with current stay-at-home rules limiting activity levels—the lockdown cost of weight gain. Even more worrying is that the resultant economic downturn may worsen obesity, especially in the most vulnerable individuals, a risk that governments need to address after the current pandemic. Indeed, this pandemic has highlighted that more—not less—must be done to tackle and prevent obesity in societies for the prevention of chronic disease and greater adverse reactions to viral pandemics.” But, again, no advice on specific government actions during the pandemic.
Also, in June 2021 was a paper making these observations:
“A Cleveland Clinic study found that survivors of COVID-19 with moderate or severe obesity have an increased risk of long-term complications of the disease, compared with patients who do not have obesity.”
“Multiple studies have identified obesity as a major risk factor for the development of severe COVID-19, which is characterized by hospital admission, intensive care and ventilator support. To our knowledge, this is the first study to suggest patients with obesity also are at increased risk for complications that last well beyond the acute phase,” says Ali Aminian, MD, director of Cleveland Clinic’s Bariatric & Metabolic Institute and first author of the study published online June 1 in Diabetes, Obesity and Metabolism.
“In this observational study, the researchers tapped a registry of patients within the Cleveland Clinic Health System who tested positive for SARS-CoV-2 infection between March 2020 and July 2020, with follow-up until January 2021. They examined three indicators of possible long-term complications of COVID-19—hospital admission, mortality and the need for diagnostic testing—that occurred a minimum of 30 days after the first positive test for SARS-CoV-2.”
“Compared with patients with normal BMI, the risk of hospital admission was 38% higher in patients with moderate obesity and 30% higher in patients with severe obesity.”
“The observations of this study possibly may be explained by the underlying mechanisms at work in patients with obesity, such as hyper-inflammation, immune dysfunction and comorbidities,” says Bartolome Burguera, MD, PhD, Chair of Cleveland Clinic’s Endocrinology & Metabolism Institute and coauthor of the study. “Those conditions are known to lead to poor outcomes in the acute phase of COVID-19 in patients with obesity and could possibly lead to an increased risk of long-term complications of COVID-19, as well.”
An article in Oct 2020 when the pandemic was headline news some important observations were made:
“Barry Popkin, PhD, of the University of North Carolina at Chapel Hill, found surprises in the numbers he and his collaborators crunched: adults with coronavirus disease who are obese had a 113% higher risk of being hospitalized and a 48% higher risk of dying from the disease than normal-weight or overweight adults.”
“In the US, we have 43% of adults who are obese and another 25% to 30% in the overweight category. We are by far the largest country with large numbers of obese individuals. Even if you move to levels of really serious obesity, BMIs [body mass indexes] of 35 or 40 or even 50, we lead the world in the proportions who are in the most severe categories.”
“We looked at all stages, from risk of getting COVID, to the risk of hospitalization, going into an intensive care unit, being put on a ventilator, and, finally, dying. What surprised me the most was that obese adults had an additional 113% risk, over normal-weight [and overweight] adults, of going into the hospital. That’s more than double the likelihood, if you’re obese, that you will be hospitalized if you test positive for COVID. Then we found that an additional 74% went into the intensive care unit if they had COVID. But even more scary was that people who were obese had an additional [48%] risk [of death] over the others. For obesity, people had talked about a small effect but hadn’t really shown the size of it in the way we have.”
Yet these startling statistics never motivated federal, state or local public health agencies to give explicit attention to obese Americans as part of pandemic management activities.
Early in the pandemic, in March 2020, it was reported that seven in 10 patients admitted in intensive care units in the United Kingdom with coronavirus were those who are obese or overweight. A British agency studied all admissions to critical care units in the UK. For the first 196 patients, 56 patients had a BMI of 25 to 30, considered overweight, while 58 had a BMI of 30 to 40, and 13 had a BMI of 40 above. But like the US, the UK did not create special government programs to address overweight and obesity as opportunities to prevent serious health impacts in the pandemic through new government efforts.
Vaccine Effectiveness for Obese People
Back in August 2020 when the pandemic was intense this Kaiser Health News article made some important observations about the COVID vaccines and whether they would be effective in obese people.
“For a world crippled by the coronavirus, salvation hinges on a vaccine.”
“But in the United States, …the promise of that vaccine is hampered by a vexing epidemic that long preceded COVID-19: obesity. Scientists know that vaccines engineered to protect the public from influenza, hepatitis B, tetanus and rabies can be less effective in obese adults than in the general population, leaving them more vulnerable to infection and illness. There is little reason to believe, obesity researchers say, that COVID-19 vaccines will be any different.”
“Will we have a COVID vaccine next year tailored to the obese? No way,” said Raz Shaikh, an associate professor of nutrition at the University of North Carolina-Chapel Hill. “Will it still work in the obese? Our prediction is no.”
“More than 107 million American adults are obese, and their ability to return safely to work, care for their families and resume daily life could be curtailed if the coronavirus vaccine delivers weak immunity for them.”
“In March, still early in the global pandemic, a little-noticed study from China found that heavier Chinese patients afflicted with COVID-19 were more likely to die than leaner ones, suggesting a perilous future awaited the U.S., whose population is among the heaviest in the world.”
“As intensive care units in New York, New Jersey and elsewhere filled with patients, the federal Centers for Disease Control and Prevention warned that obese people with a body mass index of 40 or more – known as morbid obesity or about 100 pounds overweight were among the groups at highest risk of becoming severely ill with COVID-19. About 9% of American adults are in that category.” [That suggests over 30 million Americans.]
“As weeks passed and a clearer picture of who was being hospitalized came into focus, federal health officials expanded their warning to include people with a body mass index of 30 or more. That vastly expanded the ranks of those considered vulnerable to the most severe cases of infection, to 42.4% of American adults.”
“A healthy immune system turns inflammation on and off as needed, calling on white blood cells and sending out proteins to fight infection. Vaccines harness that inflammatory response. But blood tests show that obese people and people with related metabolic risk factors such as high blood pressure and elevated blood sugar levels experience a state of chronic mild inflammation; the inflammation turns on and stays on.”
“Adipose tissue – or fat – in the belly, the liver and other organs is not inert; it contains specialized cells that send out molecules, like the hormone leptin, that scientists suspect induces this chronic state of inflammation. While the exact biological mechanisms are still being investigated, chronic inflammation seems to interfere with the immune response to vaccines, possibly subjecting obese people to preventable illnesses even after vaccination.”
“Evidence that obese people have a blunted response to common vaccines was first observed in 1985 when obese hospital employees who received the hepatitis B vaccine showed a significant decline in protection 11 months later that was not observed in non-obese employees. The finding was replicated in a follow-up study that used longer needles to ensure the vaccine was injected into muscle and not fat. Researchers found similar problems with the hepatitis A vaccine, and other studies have found significant declines in the antibody protection induced by tetanus and rabies vaccines in obese people.”
“Obesity is a serious global problem, and the suboptimal vaccine-induced immune responses observed in the obese population cannot be ignored,” pleaded researchers from the Mayo Clinic’s Vaccine Research Group in a 2015 study published in the journal Vaccine.
And most importantly: “the diminished protection of the obese population – both adults and children – has been largely ignored.”
“I’m not entirely sure why vaccine efficacy in this population hasn’t been more well reported,” said Catherine Andersen, an assistant professor of biology at Fairfield University who studies obesity and metabolic diseases. “It’s a missed opportunity for greater public health intervention.”
“In 2017, scientists at UNC-Chapel Hill provided a critical clue about the limitations of the influenza vaccine. they showed for the first time that vaccinated obese adults were twice as likely as adults of a healthy weight to develop influenza or flu-like illness. Curiously, they found that adults with obesity did produce a protective level of antibodies to the influenza vaccine, but they still responded poorly.”
“That was the mystery,” said Chad Petit, an influenza virologist at the University of Alabama. One hypothesis, Petit said, is that obesity may trigger a metabolic dysregulation of T cells, white blood cells critical to the immune response. “It’s not insurmountable,” said Petit, who is researching COVID-19 in obese patients. “We can design better vaccines that might overcome this discrepancy.”
“Historically, people with high BMIs often have been excluded from drug trials because they frequently have related chronic conditions that might mask the results. The clinical trials underway to test the safety and efficacy of a coronavirus vaccine do not have a BMI exclusion and will include people with obesity, said Dr. Larry Corey, of the Fred Hutchinson Cancer Research Center, who is overseeing the phase 3 trials sponsored by the National Institutes of Health.”
But who has seen any detailed information on currently used experimental COVID vaccines on whether they work well in obese people?
Back in August 2015 this issue of vaccine effectiveness for obese people was examined by Mayo Clinic researchers in this article: “The weight of obesity on the human immune response to vaccination.”
“The limited data concerning the effect of obesity on vaccine immunogenicity and efficacy suggests that obesity is a factor that increases the likelihood of a poor vaccine-induced immune response. Obesity occurs through the deposition of excess lipids into adipose tissue through the production of adipocytes, and is defined as a body-mass index (BMI) ≥ 30 kg/m2. The immune system is adversely affected by obesity, and these “immune consequences” raise concern for the lack of vaccine-induced immunity in the obese patient requiring discussion of how this sub-population might be better protected. Obesity is a serious global problem, and the suboptimal vaccine-induced immune responses observed in the obese population cannot be ignored.”
But it certainly looks like it has been largely ignored in the current pandemic. With a bombardment of coercive directives to get people vaccinated there has been no specific attention to the large obese population and whether vaccines should be the priority for these people. But a vaccine priority makes little sense if there is poor vaccine effectiveness in obese people.
Conclusions
The US public health system has failed to explicitly address the high fraction of obese American shown to have very high COVID risks. They place a burden on the health care system and suffer large health impacts. There is every reason to question whether COVID vaccines work effectively for this group. There is a need for focused and explicit public policies and government actions to address the population of obese people, other than placing the burden on them to eliminate their obesity through life style changes. Clearly, this “solution” has not worked for most obese people, especially among children and black and brown ethnic groups.
A recent article noted “The current national adult obesity rate is 29.7%, but almost half of adults are projected to be obese, not just overweight, by 2030, according to Harvard researchers estimates.” But population averages are somewhat deceiving. Here is some detailed data: “In the US the greatest prevalence of obesity and overweight was found among men aged 50 to 54 (80%) and women aged 60 to 64 (73%). Among Americans under age 20, the greatest prevalence in being overweight or obese was found among children ages 10 to 14, with boys at 38% and girls at 37%.”
Indeed, in 2020 CDC said that obesity was increasing. But the closest it got to public policy was saying there was a need to “remove barriers to healthy living and ensure that communities support a healthy, active lifestyle for all.” Hardly a call for action by the public health system during the pandemic and the obesity epidemic.
A 2021 paper “Public Health Considerations Regarding Obesity” made the case for new public policy approaches. It said: “The failure of the traditional obesity control measures has stressed the importance of a new non-stigmatizing public policy approach, shifting away from the traditional focus on individual behavior change towards strategies dealing with environmental change.”
Yet even the scourge of the pandemic has not motivated this by the government and public health system. Considering the vast numbers of overweight and obese American, several billion dollars should be aimed at public health agencies to create new programs to reduce both health conditions. If following the science is truly embraced by the government in this pandemic. This makes more sense than depending on vaccines which have many safety issues. Especially when you acknowledge that overweight and obese individuals are very likely to be at greater risk from health impacts of COVID experimental vaccines.
Dr. Joel S. Hirschhorn, author of Pandemic Blunder, and many articles on the pandemic, worked on health issues for decades. As a full professor at the University of Wisconsin, Madison, he directed a medical research program between the colleges of engineering and medicine. As a senior official at the Congressional Office of Technology Assessment and the National Governors Association, he directed major studies on health-related subjects; he testified at over 50 US Senate and House hearings and authored hundreds of articles and op-ed articles in major newspapers. He has served as an executive volunteer at a major hospital for more than 10 years. He is a member of the Association of American Physicians and Surgeons, and America’s Frontline Doctors.
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https://trialsitenews.com/missed-public-health-opportunity-fighting-pandemic-by-fighting-obesity/