more_vert
TO say COVID-19 has turned every country on its head, causing unprecedented public health, economic and societal pressure, is a colossal understatement. With no known therapies or preventive vaccine, the novel SARS-CoV-2 strain is responsible globally to date for over 450 000 deaths, more than 8 million infections and a global economic and social shutdown.
The development of a safe and effective vaccine against SARS-CoV-2, while being undertaken at breakneck speed, remains elusive.
The lack of an effective preventive vaccine highlights the importance of understanding what modifiable lifestyle factors predispose an individual to the development of severe COVID-19, including the requirement for mechanical ventilation and death. Recent analyses of adults under the age of 60 years hospitalised with COVID-19 in the US, France and many other countries clearly indicate individuals with severe obesity with a BMI over 35kg/m2 have a significantly greater risk (over 7 times that of individuals with a BMI less than 25kg/m2) of needing mechanical ventilation, with almost 50% of hospitalised patients with COVID-19 having obesity (here, and here). In a recent study in the US of patients with COVID-19 that required ICU admission, obesity was a significant clinical factor associated with severe COVID-19 in younger individuals (under 40 years of age). Moreover, it appears men are more susceptible to severe COVID-19 than women. Whether this gender difference is due to genetic, hormonal or behavioural factors remains unclear.
The many known underlying pathological effects of obesity may increase the risk of developing severe COVID-19. These include effects on the cardiorespiratory and immune systems and appear independent of the adverse effects of diabetes. Of relevance to COVID-19 are the effects of obesity on:
- development of a pro-inflammatory state;
- reduced respiratory reserve, including central and peripheral obstructive sleep apnoea and obesity-related hypoventilation syndrome;
- impairment of immune function secondary to nutritional micro- and macronutrient deficiencies and imbalances; and
- lack of adequate physical activity and sleep (here, and here).
In keeping with potential nutritional deficits and imbalances in individuals with obesity, a recent intriguing report suggested that vitamin D deficiency may be a possible modifiable risk factor and that vitamin D supplementation may prevent or ameliorate severe COVID-19, although the authors’ conflict of interest statement should be noted. This report is consistent with the known role of vitamin D as an anti-inflammatory agent. It also emphasises the importance of families in experiencing more outdoor activities together in natural settings; adequate and safe sunshine exposure through the effects of UV B light exposure on vitamin D pre-hormones in the skin may be the easiest and most reliable source of vitamin D for children and adults alike, depending on season, latitude and skin pigmentation.
Recent alarming reports have appeared of younger individuals (under 50 years of age) being severely affected by COVID-19-induced thrombotic strokes and COVID-19 affecting young children with a Kawasaki-like pro-inflammatory illness called paediatric multisystem inflammatory syndrome (PMIS). The influences of modifiable lifestyle factors on these rare non-respiratory manifestations of severe COVID-19 remain to be determined.
The obesity and COVID-19 link is troubling given that up to two-thirds of the adult population and a quarter to a third of children and adolescents fall into the overweight or obese range. Obesity also disproportionately affects many families from ethnic minorities and socially disadvantaged communities, who are generally ill-equipped to deal with the health and economic challenges of severe obesity, let alone COVID-19. This is a particularly highlighted in the US where the African-American population is disproportionately affected by COVID-19 (here, and here). Because the COVID-19 caseload in Australia has been small by comparison to the US and Europe, this ethnic and social disparity in COVID-19 infection, morbidity and mortality in Australia has not been apparent. This does not preclude all Australian families at high risk of obesity and diabetes, from all our nation’s many diverse ethnic backgrounds, to prioritise their family’s health and well-being.
In response to the need for improving safe opportunities for physical activity during the COVID-19 pandemic, the UK government recently announced 2 billion pounds of funding for expanding cycling and walking infrastructure. Anectodally, more urban Australian families during the COVID-19 pandemic appear motivated to cycle and walk. Initiated by Dr Ben Beck from the School of Public Health at Monash University, several medical, public health and transport researchers and relevant health organisations have written to the federal and all state governments in Australia calling for them to urgently expand funding for walking and cycling infrastructure for improved mental and physical health and wellbeing for all Australians. The recent appearance of pop-up cycle paths in several Australian cities has heeded this call for safer cycling opportunities.
As practising paediatric and adult endocrinologists dealing on a daily basis with children and their families with severe to extreme obesity, it seems apparent and urgent to us that the next 12-24 months represent a golden opportunity for starting a nation-wide public health campaign to improve family nutrition, physical activity and mindful living.
Such a campaign would help motivate families to make whole of family lifestyle changes so children, parents and grandparents alike can move to a healthier weight and live a more active purposeful life with improved social connection. Such family lifestyle changes are likely to also have a major positive impact on improving mental health, which is a major barrier to personal and family healthy behavioural change.
The motivation to make change in a family often falls on the mother, but in light of an increased risk of severe COVID-19 in males, it underscores the imperative that adult males within a family start taking greater responsibility to support their partner’s efforts for healthy family change and social connection. Improved strategies for supporting males of all ages to improve their self-care and thus support their family’s health are required. Greater public attention and support for this important public health priority is growing through organisations such as Beyond Blue, R U OK?, the Banksia Project and Spanner in the Works (delivered by the Australian Men’s Shed Association and Healthy Male).
We call upon all individuals and especially parents, with the support of your health professional team, to take on this 2020 Family Health Challenge. Then all Australian families can start a more positive family life journey together for a healthier weight, better mental and physical wellbeing, and better health and connection to their community, while also reducing their risk of severe COVID-19.
Associate Professor Gary Leong is Senior Staff Specialist in paediatric endocrinology and diabetes at the Nepean Blue Mountains Family Metabolic Health and Paediatric Diabetes Services, Nepean Hospital and the Nepean Charles Perkins Centre Research Hub. He writes under the pseudonym Dr Koala.
Dr Kathryn Williams is a Conjoint Senior Lecturer at the University of Sydney and the Clinical Lead and Manager for the Nepean Family Metabolic Health Service, a tertiary, public, whole of lifespan obesity service in the Nepean-Blue Mountains Local Health District. She is a staff specialist in endocrinology at Nepean Hospital.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
New CDC review of risk factors for severe COVID-19 even in the relative young 30kg/m2!
https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/evidence-table.html
Gary thanks for your reply. You seem to have missed my point. There are only 2 sexes as defined by the sex chromosomes – XX which is male and XY which is female. Abnormalities such as XXY and XYY are incredibly rare. How you self identify – which is gender – is infinitely variable between individuals, and within individuals!
And Sam, the world would take bariatric surgeons more seriously if you actually did a randomised controlled trial of surgery versus the one thing that actually targets IR (surgery serendipitously reduces it, not eliminates it) and that’s intermittent fasting (and that’s not calorie restriction BTW which has been shown to fail). However, the non-surgical arm would require $25000 for a life-coach for each patient to teach them how to do it properly. That’s a full-time person for about 4 months. Because that’s what the bariatric operation costs. Perhaps you could explain the reluctance of the surgical fraternity to do this (actually I think I know the answer already). As you know I’m a gut surgeon, but I prefer to address things scientifically.
Only 3-5% of obese individuals can maintain significant weight loss more than 2years with diet and exercise. No matter how many billions of dollars society throws at prevention it is obvious that it is not working. With Covid19 we now have another morbidity that can be improved with weight loss. Bariatric surgery is low risk and can eliminate insulin resistance as well as improve multiple co-morbidities and reduce overall mortality. Our government now needs to provide equitable access to this option in both public and private health systems.
Dear Dr Andrew Renaut, Thank you for your comments. I do acknowledge the importance of insulin resistance in my patients including many young children that I see in my clinics as a critical factor in weight gain – this is implied but perhaps not adequately explained in the article when we talk about the proi-inflammatory state which as you know is due to various adipokines/cytokines which impact adversely on insulin signalling and hence lipogenesis via SREPB1c and tother related adipogenic pathways in skeletal muscle and the liver to cause ectopic lipogenesis and IR. I refer you to my recently published book “Ride to Life” where I highlight the importance of insulin signalling and resistance citing the excellent work of my paediatric endocrine colleague Profesor David Ludwig from Boston Children’s Hospital, who in his various published scientific papers and books including “Ending the Food Fight “and “Always Hungry” outline clearly for the lay public the IR hypothesis in obesity pathogenesis. My own reserrach in adolescents with obesity and insulin resistance highlights IR as a risk factor for cardiomyopathy supports a critical role of insulin resistance in obesity-related heart disease (Am J Cardiology 2015 Dahiya R et al). Please let me know if you would like a free ebook download of my book as it may be helpful for some of your young clients of parenting age struggling with their own weight, and who may be embarking on the most important job in their lives i.e. being a parent! kind regards Dr “Koala”
PS My understanding is that there we have more than 2 genders (male or female) in contemporary society with an “Other” which could encompass many different genders being an option with Transgender and variations there of ! https://teentalk.ca/learn-about/gender-identity/#:~:text=There%20are%20more%20than%20two,genitals%20they%20were%20born%20with). Andf the excellent NAT GEO article a few years ago https://www.nationalgeographic.com/magazine/2017/01/how-science-helps-us-understand-gender-identity/
“No bread; No Rice; No pasta and No Processed Food. Consume Full fat milk, Natural Yoghurt, Butter, Bacon, Eggs, Red Meat, Fish, Legumes . Add some Nuts and loads of Veggies- Exercise to refine and renew the muscles to use excess glucose”
Insulin Resistance is the reason Homo Sapiens exist. Hard to cope with IR in your genes in a modern Obesogenic World where Sugar is in almost everything; Excess glucose is a villain which makes us fat and that increases in our BMI, which in many, Epigenetically drags the IR gene out of hiding and results in the Obesity Epidemic and its horrible consequences.
CSIRO has it mostly right with their Low carbohydrate, High Protein Diet.
That’s what I tell my patients.
Worth a look!!!
Nothing will change with obesity until doctors themselves understand the underlying problem and I see nothing in this article that even hints at the possibility that the authors indeed do. The reason people with obesity do badly with Covid-19 is exactly the same reason they do badly with nearly every other pathology. And that’s because of suboptimal immune cell function secondary to the insulin resistance (IR). IR also promotes obesity (not the other way around as most doctors think). Obesity and disease therefore is just an association. So to get rid of obesity you have to educate people how to eliminate IR which is remarkably easy.
Two errors BTW: Firstly male and female are sexes not genders, and there are only 2. Second, cardiovascular exercise is essential but you will not exercise the weight off – that’s because it doesn’t specifically target IR.
Congratulations for a timely reminder that there are a number of modifiable lifestyle factors that influence outcomes from disease states, even those caused by a recently emergent infectious agent. If adopted, recommendations and public health policy initiatives to cease smoking, increase exercise and physical activity, and consume a healthy diet will reduce the population burden of obesity, diabetes, hypertension, chronic obstructive lung disease and some cancers. While the global effort to develop a vaccine against and identify safe and effective treatments for SARS-CoV2 infection continues, we have a shared responsibility to assist our patients and the broader community to live healthier lives. The social and economic benefits of these measures will long outlive the current (and next) pandemic.