Body Mass Index and Risk for Intubation or Death in SARS-CoV-2 Infection

Anderson, Michaela R.; Geleris, Joshua D.; Anderson, David R.; Zucker, Jason; Nobel, Yael R.; Freedberg, Daniel E.; Small-Saunders, Jennifer L.; Rajagopalan, Kartik N.; Greendyk, Richard; Chae, Sae Rom; Natarajan, Karthik; Roh, David; Edwin, Ethan A.; Gallagher, Dympna; Podolanczuk, Anna J.; Barr, R. Graham; Ferrante, Anthony W.; Baldwin, Matthew R.

doi:10.7326/m20-3214

Cited by 195 publications

(222 citation statements)

References 68 publications

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“…[7] Furthermore, our results provide important insights on the higher risk of COVID-19 related death for low BMIs (≤19kg/m 2 ); while other studies also found this trend in their effect estimates, these were not significant, likely due to their smaller sample sizes. [7,39,40] We also found that mortality risk related to an increased BMI was higher among individuals aged 69 years or younger compared to older adults. Four previous studies are much in line with our findings, while the opposite was reported in a meta-analysis.…”

Section: Possible Explanationsmentioning

confidence: 51%

“…Four previous studies are much in line with our findings, while the opposite was reported in a meta-analysis. [7,33,36,39,40] Finally, we observed the risk of death after a hospitalisation with COVID-19 associated with BMI was higher among females, compared to males. The results of a study conducted among UK Biobank participants were congruent with our findings, while one performed in a New York hospital found a higher risk among males and others found opposite or null differences by sex.…”

Section: Possible Explanationsmentioning

confidence: 83%

“…The results of a study conducted among UK Biobank participants were congruent with our findings, while one performed in a New York hospital found a higher risk among males and others found opposite or null differences by sex. [7,33,36,39,40] Further studies are recommended to investigate this aspect.…”

Section: Possible Explanationsmentioning

confidence: 99%

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Body mass index and risk of COVID-19 diagnosis, hospitalisation, and death: a population-based multi-state cohort analysis including 2,524,926 people in Catalonia, Spain

Recalde

Pistillo

Fernández-Bertolín

et al. 2020

Preprint

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ObjectiveTo investigate associations between body mass index (BMI) and risk of COVID-19 diagnosis, hospitalisation with COVID-19, and COVID-19-related death, accounting for potential effect modification by age and sex.DesignPopulation-based cohort study.SettingPrimary care records covering >80% of the Catalonian population (Spain), linked to region-wide testing, hospital, and mortality records from March to May 2020.ParticipantsPeople aged ≥18 years with at least one measurement of weight and height from the general population and with at least one year of prior medical history available.Main outcome measuresCause-specific hazard ratios (HR) with 95% confidence intervals for each outcome.ResultsOverall, 2,524,926 participants were followed up for a median of 67 days. A total of 57,443 individuals were diagnosed with COVID-19, 10,862 were hospitalised with COVID-19, and 2,467 had a COVID-19-related death. BMI was positively associated with being diagnosed as well as hospitalised with COVID-19. Compared to a BMI of 22kg/m2, the HR (95%CI) of a BMI of 31kg/m2 was 1.22 (1.19-1.24) for COVID-19 diagnosis, and 1.88 (1.75-2.03) and 2.01 (1.86-2.18) for hospitalisation without and with a prior outpatient diagnosis, respectively. The relation between BMI and risk of COVID-19 related death was J-shaped. There was a modestly higher risk of death among individuals with BMIs≤19 kg/m2 and a more pronounced increasing risk for BMIs ≥37 kg/m2 and ≥40 kg/m2 among those who were previously hospitalised with COVID-19 and diagnosed with COVID-19 in outpatient settings, respectively. The increase in risk for COVID-19 outcomes was particularly pronounced among younger patients.ConclusionsThere is a monotonic association between BMI and COVID-19 infection and hospitalisation risks, but a J-shaped one with mortality. More research is needed to unravel the mechanisms underlying these relationships.Summary boxesSection 1: What is already known on this topicA high body mass index (BMI) has previously been associated in a linear and non-linear fashion with an increased risk of multiple health outcomes; these associations may vary by individual factors such as age and sex.Obesity has been identified as a risk factor for COVID-19 severity and mortality. However, the role of general adiposity in relation to COVID-19 outcomes has mostly been studied by dichotomizing BMI (below or above 30 kg/m2) or by a diagnostic code indicating obesity.Two studies have investigated BMI (as a continuous variable) in relation to COVID-19 outcomes, accounting for non-linearity: one conducted in a tested population sample of the UK Biobank found BMI is related in a dose-response manner with the risk of testing positive for COVID-19; another conducted in a hospital setting in New York reported a J-shaped association between BMI and the risk of intubation or death. These studies were limited in sample size and were prone to collider bias due to the participant’s restriction to tested and hospitalised patients. No studies have described the association between BMI and COVID-19 outcomes across the natural history of the disease (from no disease to symptomatic disease, hospitalisation, and mortality) using data from diverse health settings.Section 2: What this study addsWe provide a comprehensive analysis of the association between BMI and the course of the COVID-19 disease in the general population of a Spanish region during the first wave of the pandemic, using linked data capturing outpatient clinical diagnoses, RT-PCR test results, hospitalisations, and mortality (inside and outside of the hospital setting).We found that BMI is positively associated with being diagnosed as well as hospitalised with COVID-19, and is linked in a J-shaped fashion with the risk of COVID-19 related death.The association between BMI and COVID-19 related outcomes is modified by age and sex; particularly, the risk of COVID-19 outcomes related to increased BMI is higher for those aged between 18 and 59 years, compared to those in older age groups.

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Section: Possible Explanationsmentioning

confidence: 51%

Section: Possible Explanationsmentioning

confidence: 83%

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Body mass index and risk of COVID-19 diagnosis, hospitalisation, and death: a population-based multi-state cohort analysis including 2,524,926 people in Catalonia, Spain

Recalde

Pistillo

Fernández-Bertolín

et al. 2020

Preprint

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“…Interestingly, similar findings were observed in a retrospective series of COVID‐19 patients in New York City, with a positive association between obesity (BMI ≥35 kg/m 2 ) and ICU admissions in patients younger than 60 years (OR: 3.6 [95% CI: 2.5‐5.3], P < .0001), but not in those who were older than 60 years (OR: 1.5 [95% CI: 0.9‐2.3], P = .10) 23 . While this article was being prepared, Anderson et al also showed that a gradual association between obesity and IMV or death is observed in adults younger than 65 years who were hospitalized for COVID‐19, but not in patients who were older than 65 years 24 . Altogether, this reinforces the need for specific clinical management and dedicated trials in elderly people affected by COVID‐19.…”

Section: Discussionmentioning

confidence: 89%

Relationship between obesity and severe COVID‐19 outcomes in patients with type 2 diabetes: Results from the CORONADO study

Smati

Tramunt

Wargny

et al. 2020

Diabetes Obesity Metabolism

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Aim To assess the relationship between body mass index (BMI) classes and early COVID‐19 prognosis in inpatients with type 2 diabetes (T2D). Methods From the CORONAvirus‐SARS‐CoV‐2 and Diabetes Outcomes (CORONADO) study, we conducted an analysis in patients with T2D categorized by four BMI subgroups according to the World Health Organization classification. Clinical characteristics and COVID‐19–related outcomes (i.e. intubation for mechanical ventilation [IMV], death and discharge by day 7 [D7]) were analysed according to BMI status. Results Among 1965 patients with T2D, 434 (22.1%) normal weight (18.5‐24.9 kg/m 2 , reference group), 726 (36.9%) overweight (25‐29.9 kg/m 2 ) and 805 (41.0%) obese subjects were analysed, including 491 (25.0%) with class I obesity (30‐34.9 kg/m 2 ) and 314 (16.0%) with class II/III obesity (≥35 kg/m 2 ). In a multivariable‐adjusted model, the primary outcome (i.e. IMV and/or death by D7) was significantly associated with overweight (OR 1.65 [1.05‐2.59]), class I (OR 1.93 [1.19‐3.14]) and class II/III obesity (OR 1.98 [1.11‐3.52]). After multivariable adjustment, primary outcome by D7 was significantly associated with obesity in patients aged younger than 75 years, while such an association was no longer found in those aged older than 75 years. Conclusions Overweight and obesity are associated with poor early prognosis in patients with T2D hospitalized for COVID‐19. Importantly, the deleterious impact of obesity on COVID‐19 prognosis was no longer observed in the elderly, highlighting the need for specific management in this population.

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“…It is possible that individuals with obesity (and with chronic inflammation) mount a delayed inflammatory response after Covid-19-a phenomenon seen with influenza [48]. Previous studies have shown that individuals with obesity may have impaired macrophage activation and B-and T-cell responses after viral infection [14,48] and their ability to control viral replication is impaired. Secondly, BMI may not be an adequate marker of visceral body fat; it serves as a mere surrogate for central or ectopic adiposity [13,30,37].…”

Section: Discussionmentioning

confidence: 99%

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Body Mass Index and Risk for Intubation or Death in SARS-CoV-2 Infection

Cited by 195 publications

References 68 publications

Body mass index and risk of COVID-19 diagnosis, hospitalisation, and death: a population-based multi-state cohort analysis including 2,524,926 people in Catalonia, Spain

Body mass index and risk of COVID-19 diagnosis, hospitalisation, and death: a population-based multi-state cohort analysis including 2,524,926 people in Catalonia, Spain

Relationship between obesity and severe COVID‐19 outcomes in patients with type 2 diabetes: Results from the CORONADO study

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