Obesity as an aggravating factor of COVID-19 in hospitalized adults: an integrative review

Silva, Giordana Maronezzi da; Pesce, Giovanna Brichi; Martins, Débora Cristina; Carreira, Lígia; Fernandes, Carlos Alexandre Molena; Jacques, André Estevam

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Acta Paulista de Enfermagem

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Review Article • Acta Paul Enferm. 34 • 2021 • https://doi.org/10.37689/acta-ape/2021AR02321 copy

Obesity as an aggravating factor of COVID-19 in hospitalized adults: an integrative review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To identify, in scientific literature, the relationship of obesity as an aggravating risk factor for morbidity by COVID-19.

Methods:

This is a bibliographic and integrative literature review study, in Brazilian Portuguese, English and Spanish languages, through PICo strategy, in the PubMed, Scopus, Web of Science, Embase and VHL databases, held from May to June 2020. Primary articles conducted with adults, available in full, published during the period 2019 to 2020, in Brazilian Portuguese, English and Spanish were included. Case reports, clinical cases, dissertations, theses, the already selected in the search in another database and that did not answer the question of the search were excluded.

Results:

The selection resulted in nine studies. Four studies - 44.4% (E3, E5, E6 and E7) - presented the prevalence of obesity in adults hospitalized by COVID-19. Two studies - 22.2% (E6, E9) - associated obesity with the development of severe COVID-19. Three studies - 33.3% (E1, E4 and E7) - associated obesity with the need for mechanical ventilation. Three studies - 33.3% (E2, E4 and E8) - associated obesity with mortality due to COVID-19.

Conclusion:

Obesity is a chronic non-communicable disease, being a risk factor considered important for the worsening of COVID-19 disease, however, it is preventable, because healthy lifestyle habits can reduce the severe picture of COVID-19 infection.

Keywords
Coronavirus infections; COVID-19; SARS CoV2; Obesity; Risk factors

Database	Search expression	Results
PubMed https://pubmed.ncbi.nlm.nih.gov/	Search (SARS virus OR SARS- Cov OR “SARS coronavirus” ORCOVID-19 OR SARS-CoV-2 OR coronavirus OR “coronavirus infections “OR “coronavirus infection” OR coronaviridae) AND obesity AND adult AND hospitalization	10
Scopus http://www.periodicos.capes.gov.br/	TITLE-ABS- KEY:(coronavirus OR COVID 19 OR sars AND cov2 OR coronavirus AND infection AND obesity AND adult AND hospitalization)	9
Web of Science http://www.periodicos.capes.gov.br/	Basic Search- All fields: (SARS virus OR SARS- Cov OR “SARS coronavirus” OR COVID-19 OR SARS-CoV-2 OR coronavirus OR “coronavirus infections” OR “coronavirus infection “OR coronaviridae) AND obesity AND adult AND hospitalization	1
Embase http://www.periodicos.capes.gov.br/	Quick Search: (coronaviridae OR coronaviridae infection ORCOVID 19 OR sars coronavirus) AND obesity AND adult AND hospitalization	24
VHL http://brasil.bvs.br/	Title, abstract, subject: (coronavírus OR “infecção por coronavírus”) AND obesidade AND adulto AND hospitalização	1

Study	Reference	Database	Source	Study type/evidence level	Results
E1	Kalligeros, et al. (2020)⁽⁴4. Kalligeros M, Shehadeh F, Mylona EK, Benitez G, Beckwith CG, Chan PA, et al. Association of obesity with disease severity among patients with coronavirus disease 2019. Obesity (Silver Spring). 2020;28(7):1200–4.⁾	Embase	USA	Cohort Retrospective Level IV	- 103 patients hospitalized by COVID-19. - February 17 to April 5, 2020. -The prevalence of obesity was 47.5% (49 out of 103). -In a multivariate analysis, severe obesity (BMI ≥ 35 kg/m²) was associated with admission to the Intensive Care Unit (adjusted Odds Ratio [OR]: 5.39, 95% CI: 1.13‐25.64). -Patients requiring invasive mechanical ventilation were more likely to be obese (BMI = 30‐34.9 kg/m²; aOR: 6.85, 95% CI: 1.05‐ 44.82) or severe obesity (BMI ≥ 35 kg/m²; aOR: 9.99, 95% CI: 1.39-71.69).
E2	Hur et al. (2020)⁽¹⁴14. Hur K, Price CP, Gray EL, Gulati RK, Maksimoski M, Racette SD, et al. Factors associated with intubation and prolonged intubation in hospitalized patients with COVID-19. Otolaryngol Head Neck Surg. 2020;163(1):170–8.⁾	PubMed	Chicago - USA	Observational Level VI	- 564 patients hospitalized between March 1 and April 8, 2020 positive for COVID-19. -Age, males and history of diabetes were independent risk factors associated with intubation in patients hospitalized with COVID-19 in the Chicago metropolitan area. -The time for extubation was influenced only by age and obesity. Patients intubated with COVID-19 with BMI from 30 to 39.99 (HR, 0.53; 95%, 0.32-0.90) or ≥40 (HR, 0.40; 95%, 0.19-0.82 CI) were associated with a lower chance of extubation compared to patients with a <30.
E3	Docherty AB, et al. (2020)⁽¹⁵15. Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L, Holden KA, Read JM, Dondelinger F, Carson G, Merson L, Lee J, Plotkin D, Sigfrid L, Halpin S, Jackson C, Gamble C, Horby PW, Nguyen-Van-Tam JS, Ho A, Russell CD, Dunning J, Openshaw PJ, Baillie JK, Semple MG; ISARIC4C investigators. Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterization Protocol: prospective observational cohort study. BMJ. 2020;369:m1985.⁾	PubMed	United Kingdom	Prospective Cohort Level IV	-20,133 patients hospitalized with COVID-19 between February 6 and April 19. -The factors associated with hospital mortality were increased age, males, obesity (Risk Ratio 1.33; CI 95% 1.19 to 1.49; P<0, 001) and important comorbidities.
E4	Cummings, et al. (2020)⁽¹⁶16. Cummings MJ, Baldwin MR, Abrams D, Jacobson SD, Meyer BJ, Balough EM, et al. Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study. Lancet. 2020;395(10239):1763–70.⁾	PubMed	New York - USA	Prospective Cohort Level IV	-257 adults in serious condition of COVID-19 between 2 March and 1 April 2020. - 119 (46%) patients were obese (BMI ≥30 kg/m²), including 39 (71%) of the 55 patients under 50 years old - Severe obesity (BMI ≥40 kg/m²) was not identified as an independent risk factor for mortality.
E5	Palaiodimos, et al. (2020)⁽¹⁷17. Palaiodimos L, Kokkinidis DG, Li W, Karamanis D, Ognibene J, Arora S, et al. Severe obesity, increasing age and male sex are independently associated with worse in-hospital outcomes, and higher in-hospital mortality, in a cohort of patients with COVID-19 in the Bronx, New York. Metabolism. 2020;108:154262.⁾	Scopus	Bronx, New York- USA	Cohort Retrospective Level IV	-200 patients who attended the emergency room from March 9 to April 12, 2020. - 24% of the cohort died during hospitalization, with higher rates among individuals with severe obesity (BMI <25 kg/m²: 31.6%, BMI 25-34 kg/m²: 17.2%, BMI ≥ 35 kg/m²: 34.8%, p= 0.030). - Patients with severe obesity were more likely to suffer intubation (BMI <25 kg/m²: 18.4%, BMI 25-34 kg/m²: 16.4%, BMI ≥ 35 kg/m²: 34.8%, p= 0.032). - Severe obesity BMI ≥ 35 kg/m² (OR: 3.09; 95% CI: 1.43–6.69; p= 0.004), increasing age, males and smoking were also independently associated with increased oxygen requirements during hospitalization.
E6	Richardson et al. (2020)⁽¹⁸18. Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al.; the Northwell COVID-19 Research Consortium. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City Area. JAMA. 2020;323(20):2052–9.⁾	Scopus	New York - USA	Observational Level VI	- A total of 5,700 patients (median age 63 years) were included from March 1 to April 4, 2020. The most common comorbidities were hypertension (3026; 56.6%), obesity (1737; 41.7%), and diabetes (1808; 33.8%).
E7	Hamer, et al. (2020)⁽¹⁹19. Hamer M, Kivimäki M, Gale CR, Batty GD. Lifestyle risk factors, inflammatory mechanisms, and COVID-19 hospitalization: A community-based cohort study of 387,109 adults in UK. Brain Behav Immun. 2020;87:184–7.⁾	Scopus	England	Prospective Cohort Level IV	-387,109 people. Of these, 760 were hospitalized by COVID-19. -March 16 to April 26, 2020. - 23.5% were obese. - There was a dose-dependent association between the risk of COVID-19 and the worsening of lifestyle scores so that participants, in the most unfavorable category, had a four-fold higher risk (RR = 4.41; CI 95%, 2.52, 7.71). - After adjusting for age, sex and mutually for each lifestyle factor, sedentary lifestyle (RR 1.32, 95% CI, 1.10, 1.58), smoking (RR 1.42; 95% CI 1.12, 1.79) and obesity (RR 2.05; CI95% 1.68, 2.49) were associated with COVID-19. -Unhealthy behaviors in combination (smoking, inactivity, overweight and obesity) represented up to 51% of the fraction attributable to the severe COVID-19 population. - Overweight and obesity are risk factors for severe COVID-19 infection.
E8	Klang, et al. (2020)⁽²⁰20. Klang E, Kassim G, Soffer S, Freeman R, Levin MA, Reich DL. Severe Obesity as an Independent Risk Factor for COVID-19 Mortality in Hospitalized Patients Younger than 50. Obesity (Silver Spring). 2020;28(9):1595-9.⁾	Embase	New York - USA	Observational Level VI	-3,406 patients were included; 572 were under 50. -March 1 and May 17, 2020. - For the younger population, BMI above 40 kg/m²was independently associated with mortality (OR 5.1, 95% CI 2.3-11.1). -For the elderly population, BMI above 40 kg/m² was also independently associated with mortality to a lesser degree (OR 1.6, 95%CI 1.2 - 2.3).
E9	Cai, et al. (2020)⁽²¹21. Cai Q, Chen F, Wang T, Luo F, Liu X, Wu Q, He Q, Wang Z, Liu Y, Liu L, Chen J, Xu L. Obesity and COVID-19 severity in a designated hospital in Shenzhen, China. Diabetes Care. 2020;43(7):1392-8.⁾	Embase	China	Observational Level VI	- 383 patients with COVID-19 hospitalized from January 11 to February 16, 2020. - After adjustments for potential confounding factors, those who were overweight (BMI between 24-27.9 kg/m²) had chances of 1.84 times of developing severe COVID-19 (OR 1.84, CI95% 0.99-3.43, p5 0.05), while obese (BMI ≥28 kg/m²) had a 3.40-fold chance of developing severe disease (OR 3.40, 95% CI 1.40-2.86, P5 0.007).

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[1] Corresponding author Débora Cristina Martins, E-mail: martinsdebora344@gmail.com