The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has attracted increasing worldwide attention (1). Obesity commonly aggravates the severity of respiratory diseases, but it is currently not known whether obese patients are also more likely to have greater COVID-19 severity of illness. We investigated the association between obesity and COVID-19 severity of illness among patients with laboratoryconfirmed SARS-CoV-2 infection. We enrolled adult patients with COVID-19 from three hospitals in China between 17 January 2020 and 11 February 2020. Seventy-five patients were diagnosed as obese (i.e., case subjects). We randomly matched each case subject with one control subject (nonobese) by sex (1:1) and age (65 years). The cohort thus comprised 150 patients with COVID-19. The study protocol was approved by local ethics committees of the three hospitals.

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Risk of severe illness from COVID-19 in patients with metabolic dysfunctionassociated fatty liver disease and increased fibrosis scores A recent study reported that patients with severe COVID-19 were more likely to have non-alcoholic fatty liver disease (NAFLD) compared with those with non-severe COVID-19 illness. 1 However, the prognosis of NAFLD (recently renamed metabolic dysfunction-associated fatty liver disease (MAFLD) 2) is determined by the severity of liver fibrosis. 3 4 We therefore postulated that patients with MAFLD with increased noninvasive liver fibrosis scores are at higher risk of severe illness from COVID-19. We studied 310 patients with laboratoryconfirmed COVID-19 who were consecutively hospitalised at four sites in Zhejiang Province, China, between January and February 2020. Some of these patients (n=150) have been included in a prior study examining the association between obesity and COVID-19 severity. 5 Patients with viral hepatitis, excessive alcohol consumption, chronic pulmonary diseases or active cancers were excluded. Clinical and laboratory data were collected at hospital admission. All patients were screened for hepatic steatosis by computed tomography and subsequently diagnosed as MAFLD. 6 The originally validated cut-points for fibrosis-4 (FIB-4) index and NAFLD fibrosis score (NFS) were used to categorise liver fibrosis probability as low, intermediate or high. 7 COVID-19 severity was classified as severe and non-severe. 8 The study protocol was approved by the local ethics committees of the four hospitals. In our cohort of 310 confirmed cases of COVID-19, 94 (30.3%) patients had MAFLD. As shown in table 1, patients with MAFLD with intermediate or high FIB-4 scores were more likely to be older, obese, have diabetes and have higher NFS, higher liver enzymes, higher C reactive protein, as well as lower levels of lymphocyte count, platelet count, triglycerides and high-density lipoprotein cholesterol compared with their counterparts with low FIB-4 score or those without MAFLD. Notably, the severity