In the early days of the covid pandemic, those most likely to be hospitalized or die from the virus had a few things in common.
Age was the strongest risk factor for becoming very ill with Covid. Race and ethnicity also seemed to be related, as Covid deaths were higher among blacks, Hispanics and Native Americans.
Having two or more health conditions (called comorbidities) – increased the risk of serious illness and death from Covid. But some of the comorbidities you hear a lot about, like asthma, heart disease, lung disease and diabetes, weren’t the ones that gave Covid patients the highest risk of hospitalization and death.
It was obesity.
“Obesity is a disease characterized by a chronic inflammatory process, and this process has had a major collision with multiple factors during the pandemic,” said Fatima Cody Stanford, MD, MPH, MPA, Associate Professor of Medicine at Massachusetts General Hospital and a physician scientist specializing in obesity medicine. “COVID is a acute inflammatory process, and those two things (Covid and obesity) don’t go so well together.
Studies show that social determinants of health – conditions in the environments where people are born, live, learn, work, play, love and age – have made the virus worse for people with obesity. Covid was also worse for people of color. In his 2021 TEDx ConferenceCody Stanford said people of color are battling three pandemics – obesity, racism and Covid-19.
How does obesity affect Covid?
How obesity works provides insight into why Covid has proven so deadly.
“A very simple reason was that obese patients can’t expand their lungs as much,” he said. Holly F. Lofton, MDdirector of the weight management medical program at NYU Langone Health and member of HealthyWomen’s Women’s Health Advisory Council. “If you add a respiratory disease like Covid to a condition where you already can’t expand your lungs, the mucus starts to build up and it’s really hard to push it out.”
Lofton noted that obese people typically have a larger waist circumference, defined as more than 35 inches in a woman or 40 inches in a man. This midsection weight pushes on the diaphragm, making the chest cavity around the smaller lungs. For a Covid patient, this smaller chest cavity leaves less room to breathe when breathing is most needed.
Fat itself causes inflammation. Release of fat cells cytokines, which are inflammatory hormones that can worsen immune function. Obese people have high levels of one of these cytokines (Interleukin-6 or IL-6), and high levels of IL-6 were associated with poor outcomes in Covid patients.
Inflammation due to obesity is also a risk factor for blood clots. Lofton said she warns obese people who are otherwise healthy before having weight-loss surgery about the risk of clots forming. Blood clots can occur in response to infection or lack of movement. Blood might be more likely to clot in reaction to covid inflammationand when clots travel to the arteries and veins of organs, it can lead to heart attack, stroke, organ damage, or death.
When obesity, social determinants of health and Covid collide
Obesity is a disease. A study by the Centers for Disease Control and Prevention (CDC) tracking obesity rates found that Black/African American women had the highest rates of obesity compared to any other racial group at 57%. Among Hispanic women, 44% were living with obesity. Non-Hispanic white women had an obesity rate of 40%, while Asian women had the lowest obesity rates at 17%. A different study showed that 48% of all Native Americans suffered from obesity.
Like other diseases, obesity is affected by social determinants of healthwith many of the following factors contributing to its development.
- Racism and discrimination: Historical and current race-based inequalities in health care, housing, education, criminal justice, and the economy have been shown to contribute to obesity.
“The Black Women’s Health Study was the first to really show how exposure to racism itself predisposes you to a higher risk of obesity,” Cody Stanford said. “When you experience racism as a black person here in the United States or elsewhere, you feel stress. Stress causes the storage of fat (adipose tissue).
There was certainly no shortage of chronic stress in 2020, from people losing friends and family to Covid to the public exposure of acts of racial violence, such as the killings of George Floyd, Breonna Taylor and Ahmaud Arbery.
- Health care access: A lack of insurance, transportation, childcare, or the ability to take time off work can make it more difficult to see a health care provider (HCP). Cultural differences, language barriers and provider biases can also affect the quality of health care people receive.
Lofton noted that the medical mistrust of people of color, stemming from historical examples like the Tuskegee Syphilis Study And forced sterilization of black, Latina and Native American womenas well as personal experiences of poor care can reduce the likelihood that people from marginalized groups will seek treatment.
While access to health care is often tied to gaps in education, income, and wealth, people of color from higher socioeconomic backgrounds also report treatment disparities that they believe to be related to their race or ethnicity.
At the start of the pandemic in 2020, stories came out about people of color turned away from hospitals in urban areas, many of whom are dying of Covid at home. Lofton mentioned pharmaco-inequity, that is, when provider bias or lack of assurance leads marginalized groups to receive older or less effective drugs when better treatments are available. For example, when Covid drugs hit the market, people of color were less likely to receive them.
- Food deserts, food insecurity and food swamps: Areas that lack grocery stores and restaurants offering healthier and cheaper food options are called food deserts. They are found in many urban and rural areas where people of color live. Even when food is available, lower incomes can also lead to food insecurity, where people cannot afford to buy enough food.
However, there are often many fast food restaurants offering more processed and less nutritious options in these areas. Many times they are even on the same block. These areas have been referred to as food swamps.
“They’re convenient, they’re cheap, and they’re easy,” Cody Stanford said. “And when you’re stressed, what is your body looking for?” You’re looking for comforting things, and fast food can be that.
- occupations: More people of color were likely to be employed as essential workers deal with the public or perform tasks in confined spaces without the ability to work from home. They may have had less economic flexibility to quit those jobs or stay home when sick, putting them at greater risk of contracting Covid.
- weight bias: Several studies have shown that healthcare professionals have a negative bias against overweight or obese patientswhich could affect the quality of care they receive.
“There are times when a doctor has to make a decision, ‘Who am I going to give the ventilator to? There’s only one ventilator, but there are two patients who need it,'” Lofton said. , noting that weight bias could be a deciding factor in such cases.
If you are obese, you can do your best to protect yourself from Covid-19 by keeping up to date with Covid vaccines and taking preventative measures in public, such as wearing a face mask and washing your hands frequently or using a hand sanitizer. You can also improve your results by getting tested immediately if you have symptoms and contacting your healthcare professional as soon as you suspect Covid for timely treatment.
You may not be able to control many factors that contribute to getting sick from Covid. But studies suggest that treating obesity can improve your overall health and reduce the risk of poor Covid outcomes. A study found that patients who had weight loss surgery had a 60% lower risk of developing serious complications from Covid.
In addition to preventative measures, Lofton stressed the importance of ongoing education for healthcare professionals to help eliminate weight bias in healthcare.
“Physicians need to be made aware that there is an unconscious weight bias and that we should try to put that aside when treating obese patients,” Lofton said.
Cody Stanford said his goal was to improve overall health to help reduce chronic inflammation that leads to obesity and makes other diseases, such as Covid, more dangerous, while recognizing the intersection of race and class in the overall results.
“My goal is to bring people to a happier, healthier state of being,” she said. “It’s not about giving them a number on a scale, it’s about looking at cholesterol values, fasting blood sugar, insulin values, liver function – let’s look at it all together. I emphasize the health piece of the puzzle and the prevention of all the diseases that obesity can cause.
This resource was created with support from Pfizer.
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