After having read your recent Editorial “COVID 19 and the Patient with Obesity – The Editors Speak Out”1, I wish to share my own personal experience. I am an anesthesiologist working on the frontline of the coronavirus (SARS-CoV-2) pandemic at an academic and teaching establishment, Weill Cornell Medical College, New York-Presbyterian Hospital, in New York City. As Director of the Bariatric Anesthesia division, and an airway expert, I was assigned to our COVID Airway Team, in March 2020. We are at ground zero of the public healthcare crisis, intubating as many as 15-20 patients in a 24-hour period. I began to field calls from other physicians, “Could you help out. We have a 150-kg patient.” Upon closer inspection, I noted that most of my patients were male, over age 60, had extensive medical comorbidities, and obesity. They overwhelmingly possessed the obstructive sleep apnea (OSA) phenotype2..
Patients with obesity class III and full expression of the OSA phenotype, OSA Subtype B2, are already known have a high prevalence of cardiovascular disease risk, obtain less benefit from non-invasive positive pressure ventilation, and require medical management of co-morbidities. Such patients have high risk of all-cause, cardiovascular, and cancer mortality2 and often present with a deconditioned pro-inflammatory profile2. The Centers for Disease Control and Prevention classes patients with obesity at risk of flu3, and ostensibly COVID-19 complications, as has been shown in the 2009 influenza A (H1N1) infection. As pointed out in the Editorial1, these patients are at risk of infections, in particular respiratory infections, and of influenza-like illness despite vaccination3. According to the CDC, obesity (48.3%) was present in many of the hospitalized, or deceased, COVID-19 patients4. It is incumbent on hospitals to gather demographics on BMI for all admissions, in order to develop good data. Only with large datasets can the relative frequencies of hypertension, diabetes and obesity be separated out. Their individual, as well as additive, roles in the COVID-19 pandemic have yet to be determined; whether contributory or merely associative.Patients with severe obesity are highly represented in the severe COVID-19 disease population. To determine the relationship of obesity on COVID-19, national or international retrospective large-scale medical studies of hospital admissions need to be conducted. Several such smaller, or regional, studies are on-going5, and indicated that the most frequent comorbidities represented in the severe COVID-19 infected population are hypertension, obesity and diabetes. These studies offer a regional perspective, and are helpful, although they have limitations. It is difficult to compare data in disparate healthcare systems without uniform definitions of quality and outcome. Risk stratification of data points should allow resources to be deployed in the most cost-effective manner, and focus attention on the most fragile cohort of patients, during all phases of the disease. What is now needed is to harmonize these results and put them together into a large dataset from which conclusions may be drawn. The author has no funding or disclosures. Ethical standards of the author’s institution were followed in the production of this letter to the editor
Bibliography1.
Ryan DH, Ravussin E, Heymsfield S. COVID 19 and the Patient with Obesity – The Editors Speak Out. Obesity, 2020 May; 28(5):847-847.2. Zinchuk A, Yaggi HK. Phenotypic Subtypes of OSA: A Challenge and Opportunity for Precision Medicine. Chest, 2020 Feb; 157(2):356-362.3.Neidich SD, Green WD, Rebeles J, et al. Increased risk of influenza among vaccinated adults who are obese. Int J Obes (Lond) 2017; 41:1324‐1330.4.Finer N, Garnett SP, Bruun JM. COVID-19 and obesity. Clinical Obesity; 2020:1-2. Published online April 20, 2020. doi:10.1111/cob.12365. Accessed on: May 1, 2020.5. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. Published online April 22, 2020. doi:10.1001/jama.2020.6775. Accessed on: May 1, 2020
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