CDC-defined weight status categories for adults:
Underweight: BMI, <18.5 kg/m2
Normal or healthy weight: BMI, 18.5-24.9 kg/m2
Overweight: BMI, 25-29.9 kg/m2
Obese: BMI, ≥30 kg/m2
Patients with obesity face both physical and emotional challenges during the COVID-19 pandemic. How can primary care physicians help? Expert interviews and latest research shed light.
“Obesity truly is a global disease. There are now more people in the world who have excess body weight, and it’s adverse health consequences, than there are people who are underweight,” said obesity expert Donna Ryan, MD, in an interview with Patient Care Online.
According to the most recent global estimates from the World Health Organization, more than 1.9 billion adults aged ≥18 years were overweight in 2016 and of these adults, >650 million were obese. In 2019, an estimated 38.2 million children worldwide aged <5 years were overweight or obese.
And in the US, the prevalence of obesity has been increasing at a dangerous pace.
According to the Centers for Disease Control and Prevention (CDC), the obesity prevalence among adults in the US in 2017-2018 was 42.4%, an increase from 30.5% in 1999-2000 and the first time the national rate has surpassed 40%. Rates of childhood obesity are also rising, with approximately 20% of youth aged 2-19 years now affected, compared to 5.5% in the mid-1970s.
Having obesity puts patients at increased risk for many other serious chronic conditions such as type 2 diabetes and cardiovascular disease, and now the novel coronavirus disease 2019 (COVID-19) has made life even harder for these patients.
As COVID-19 began to spread more rapidly across the US in March 2020, stay-at-home orders were implemented in many states to help mitigate transmission.
Temporary closure to places of employment, restaurants, fitness facilities, and many other public places forced abrupt changes to individuals’ habitual dietary and physical activity patterns.
In turn, social isolation and its negative impact on mental health has been felt by many.
In an online survey of 1000 US adults aged ≥18 years, 59% said that their mental health had been affected by COVID-19. More specifically, 35% of participants reported feeling depressed, 37% reported feeling isolated, 48% said they felt anxious, and 49% said they felt stressed out.
Patients with obesity may be at even greater risk for mental health issues during COVID-19.
For example, a global survey published in the journal Obesity of 7753 adults both with and without obesity during the pandemic lockdown found that while anxiety scores increased for both groups, the magnitude of increase was significantly greater in those with obesity (P≤.01).
Also, in a study of obesity patients presented at ObesityWeek 2020, researchers from the University of Texas Southwestern Medical Center found that 72.8% of participants reported increased anxiety and 83.6% reported increased depression since COVID-19 stay-at-home orders were initiated.
Another component of emotional distress for patients with overweight and obesity is the specific type of social stigma they experience. The World Obesity Society defines weight stigma as the, “discriminatory acts and ideologies targeted towards individuals because of their weight and size.”
Individuals who are obese or overweight are often characterized as undisciplined, unmotivated, or unattractive. They may experience teasing, negative verbal comments, or worse, physical assault. Patients may internalize these harmful stereotypes, resulting in feelings of shame or distress about their body weight or habits.
Unfortunately, weight stigma is common and the associated emotional impact poses yet another psychological threat during the COVID-19 pandemic.
For example, a study published in the October issue of Annals of Behavioral Medicine identified weight stigma, independent of a person’s body mass index (BMI), as a factor that may worsen eating behaviors and physiological distress for young adults during the pandemic.
Researchers from the University of Connecticut Rudd Center for Food Policy and Obesity and the University of Minnesota analyzed data from 584 young adults (mean age, 24.6 years; mean BMI, 28.2 kg/m2) enrolled in the population-based longitudinal EAT (Eating and Activity over Time) 2010-2018 study, who were invited to complete a follow-up online survey during the pandemic.
Weight stigma previously reported by participants in 2018 was examined as a predictor of binge eating, eating to cope, physical activity, depressive symptoms, and stress during COVID-19. Participants who experienced weight stigma prior to COVID-19 were 3-times more likely to engage in binge eating during the pandemic vs those who had not.
“The COVID-19 crisis now has shown us the dark underbelly of American health care,” said obesity and nutrition expert Caroline M. Apovian, MD, director, Center for Nutrition and Weight Management, Boston Medical Center, in an interview with Patient Care Online. “Those who are afflicted with obesity and diabetes are so at risk for the severity of COVID-19, that they are dying.”
In the first meta-analysis of its kind, published August 26, 2020 in Obesity Reviews, an international team of researchers pooled data from 75 peer-reviewed studies capturing approximately 399 000 patients with obesity. Compared to patients of healthy weight, those with a BMI of ≥30 kg/m2 and COVID-19 were found to have:
Another study of nearly 7000 COVID-19 patients conducted by a team of researchers from Kaiser Permanente found that patients with the highest measures of BMI (≥45 kg/m2) were more than 4-times as likely to die from COVID-19.
Why are patients with obesity experiencing severe COVID-19? Waning immunity is thought to be one factor.
“Their [persons with obesity] immune systems are similar to a senescent immune system and so those younger people with diabetes and obesity are succumbing to COVID-19,” explained Apovian in the same interview.
Obesity-associated inflammation might also be a contributing factor.
“Individuals who have excess body fat can store that body fat in abnormal places, we call this ectopic body fat,” said Ryan in the same interview with Patient Care Online.
Ryan explains that body fat stored inside the abdominal cavity—the visceral fat depot—“has a much more adverse profile and it produces lots of adverse health consequences, among them are a pro-inflammatory environment.”
In one of the largest case series from the US, researchers from the New York University Grossman School of Medicine found that markers of inflammation and admission oxygen impairment were “most strongly associated” with critical illness in COVID-19 patients.
Furthermore, Harold Bays, MD, chief science officer of the Obesity Medical Association and the medical director and president of Louisville Metabolic and Atherosclerosis Research Center, explained in an interview with Healio Primary Care that obesity-related lung abnormalities, such as sleep apnea, can result in hypoxia before COVID-19 infection occurs, leaving little room for any further lung injury, as might occur with COVID-19.
“Anything that further compromises the lungs can be devastating to a patient with obesity,” said Bays.
As COVID-19 cases continue to rise globally, it is clear that pandemic conditions are not going to change anytime soon, leaving patients with obesity at risk for continued physical and mental challenges.
Weight loss might be the obvious solution to help mitigate these challenges, but Ryan cautions against it during the pandemic because weight loss is thought to increase the risk of COVID-19 infection. Patients are also hampered by reduced access to many types of physical exercise.
Where does this leave primary care physicians who are looking to support patients with obesity?
According to Ryan, physicians can simply ask patients for permission to engage in an open, empathetic conversation.
“It [the conversation] should always be framed around health. You’re not judging your patient’s body size; you’re trying to help your patient achieve a healthier status,” explained Ryan. “You can say to your patient, ‘is it okay if we discuss your weight and how it may be affecting your health?’”
Most patients with obesity are relieved when their physician starts the conversation, but if they decline, “All you have to do is say, ‘I understand, let’s agree that on our next visit, I’ll bring the topic up again and we’ll see if we can’t talk about it then,’” advised Ryan.
Discussing weight can be stressful for both primary care physicians and patients as it is a highly sensitive topic, but opening the dialog in a sincere manner might be the best way to help patients to start thinking about the impact obesity has on their health.