cord-011333-yyhwtnza	2020	Nevertheless, improving dietary intake and increasing physical activity performance are to date the best therapeutic tools in children to weaken the onset of obesity, cardiovascular diseases, and diabetes risk during adulthood. The raising prevalence of obesity, metabolic syndrome together with insulin resistance [43] , worldwide is associated with liver abnormalities encompassing the clinical spectrum of nonalcoholic fatty liver disease (NAFLD). Physical inactivity affects a vast majority of children and adolescents who become prone to high obesity rates and related diseases, including CVD and NAFLD. Nevertheless, improving dietary intake and increasing physical activity performance are to date the best therapeutic tools in children to weaken the onset of obesity, CVD, and diabetes risk during adulthood. The prevalence of non-alcoholic fatty liver disease in children and adolescents: a systematic review and meta-analysis
cord-012493-pwbzffo9	2020	• It provided information that made it likely to impact treatment response, according to the relevant literature (especially studies that aimed to stratify patients) • It was feasible: Given that each clinical trial has limits on budget and time as well as research team expertise, the OBEDIS group aimed to minimize the burden of including each variable in future trials. Data for the minimal core set should include: the number of attempts, whether the patient has undertaken individual/group behavioral interventions (pertaining to nutrition/PA/psychology), whether treatment included obesity drugs or bariatric surgery, and the maximal weight loss and weight regain as a result of these attempts. A measure of muscle strength, as an important component of muscular fitness, is therefore also recommended for the minimal core set, since the evidence in aggregate shows that muscle strength is associated with reduced mortality in all BMI categories and that resistance training (designed to increase muscle strength), even without weight loss, improves health risk [53] .
cord-034066-fsp7e5x5	2020	2 And in 2008, the Agency for Healthcare Research and Quality of the HHS came out with an Evidence-Based/Technology Assessment entitled "The Effectiveness of Weight Management Programs in Children and Adolescents." 3 In addition to these government-sponsored guidelines, recommendations for management of overweight and obesity in this population have been issued by multiple other organizations. One 12month technology-based program for adolescents with Type 2 diabetes "was not sufficient to produce weight loss with the combination of web intervention and group sessions and telephone follow up, but improvements in sedentary behavior and use of behavior change strategies expected to lead to behavior change was evidenced." 32 Telemedicine, in theory, should be able to compensate for some of the barriers that prevent access to and utilization of family based comprehensive behavioral interventions for child and adolescent obesity.
cord-261891-yiiz9s53	2020	8 Preliminary data from different cohorts of patients infected by COVID-19 of small sample size (lower than 400 patients), with short follow-up or with poorly described BMI indicate poorer prognosis in people with obesity compared to other patients. However, it is not possible to conclude from these results that obesity is an independent factor of mortality for patients infected with COVID-19 due to the small sample sizes of these studies, neither to have a precise estimate of obesity size effect due to the absence of BMI categories and incomplete follow-up. We imputed missing BMI category using predictive mean matching considering as the following as explaining variables: comorbidities (hypertension, diabetes, sleep apnea, dyslipidemia, chronic kidney disease, heart failure, cancer), smoking status, sex, age and indirect information regarding BMI value (obesity from free-text reports, variables extracted from 4-digits E66 ICD-10 codes and malnutrition ICD-10 codes).
cord-265139-x7g3jcjm	2020	There is also growing evidence that circRNAs are closely linked to non-alcoholic fatty liver disease (NAFLD), a disorder that is caused by a plethora of factors including hepatic lipid accumulation, adipose tissue and mitochondrial dysfunction, a high-fat diet, obesity, a chronic inflammatory state, insulin resistance (IR), and genetic and epigenetic factors [48, 55] . In addition to classical epigenetic modifications, a variety of ncRNAs have been uncovered in different cells and organs including adipose tissues, many of which are involved in the regulation of adipogenesis and other metabolic processes implying their role in the etiology of obesity [69] . Emerging evidence from in vitro and in vivo animal studies suggest that circRNAs are expressed in adipose tissues and may modulate adipogenesis and lipid metabolism. Collectively, the results from the above studies demonstrate that several circRNAs are differentially expressed in adipose tissue and support a significant role of these RNA species in the regulatory networks of adipogenesis.
cord-266380-lu6hj3a2	2020	In Saudi Arabia, 58% of the population are under the age of 35 years, and only 3.2% are over the age of 65 years, 2 but unfortunately, the burden of obesity in the Kingdom poses a risk of developing a more severe complicated infection. In Saudi Arabia, 58% of the population are under the age of 35 years, and only 3.2% are over the age of 65 years, 2 but unfortunately, the burden of obesity in the Kingdom poses a risk of developing a more severe complicated infection. Key challenges that were specific for obesity care, included reduced access to healthcare resources, isolating patients, limiting their physical activity, and causing disruptions in eating habits with irregular mealtimes, frequent snacking, more processed meals, and increased anxiety and depression. 5 At a time when the focus is only the immediate COVID-19 pandemic, our patients with obesity should not be lost, nor forgotten.
cord-267505-4tw7kfek	2020	However, people with obesity have an elevated risk of hospitalization, serious illness, and mortality, likely due to chronic lowgrade inflammation [1] , an altered immune response to infection, as well as related cardiometabolic comorbidities [2] , and the COVID-19 pandemic is likely to have a significant impact on people with obesity. Given that obesity is a prevalent, persistent, serious, complex, chronic, and relapsing disease among the general population [3] , it is important that we pay special attention to these challenges especially during the COVID-19 pandemic and when planning management of the aftermath to avoid placing an even greater burden on individuals, health systems, and society over the short, medium, and long term. The role of EASO is crucial in (1) identifying the particular needs of healthcare providers and persons living with obesity during the COVID-19 pandemic, (2) disseminating sciencebased information, and (3) sharing knowledge, evidence-based recommendations, and guidance toward the clinical, patient, and policy communities using social and other media, which allow us to reach millions of people across Europe.
cord-277074-1emlkii0	2020	From this point of view, we determined the obesity prevalence of the top 20 ranked countries by total deaths due to COVID-19. The data regarding the obesity prevalence of countries were obtained from global health services data of the World Health Organization [1, 2] . Herein, we believe that cardiovascular and metabolic effects, sleep apnea, vitamin D deficiency, dysregulation of the renin-angiotensin-aldosterone system (RAAS) as well as sarcopenia should be taken into account as obesity-related confounders to COVID-19. The adipose tissue can manifest as a reservoir for a wider viral spread with increased shedding, immune activation, and cytokine amplification in relevant patients as well [4, 5] . First of all, obesity is a predominant risk factor for OSA (obesity hypoventilation syndrome), and OSA patients may be vulnerable to COVID-19. The dysregulation/increase of the RAAS has been shown in OSA patients, likewise in obesity [6] . Is Adipose Tissue a Reservoir for Viral Spread, Immune Activation and Cytokine Amplification in COVID-19.
cord-277803-7p1qu2rf	2020	Given the uncertainty regarding the effects and duration of the COVID-19 outbreak, combined with the progressive nature of obesity, diabetes, and related conditions, delaying bariatric and metabolic surgery could increase the risks for morbidity and mortality in surgical candidates.
cord-288255-p8uzrsbd	2020	authors: Goossens, Gijs H.; Dicker, Dror; Farpour-Lambert, Nathalie J.; Frühbeck, Gema; Mullerova, Dana; Woodward, Euan; Holm, Jens-Christian Evidence from studies in humans indicates that people with obesity are characterized by systemic low-grade inflammation, higher susceptibility to infections, dampened immune response to infectious agents, as well as higher morbidity and mortality associated with infections, and demonstrate an impaired immune response to vaccinations and antimicrobial treatment [25] [26] [27] [28] . Together, these findings imply that evaluation of cytokine profiles and immune cell subsets in patients with SARS-CoV-2 infection, and a deeper understanding of the underlying processes, will significantly contribute to better treatment strategies and clinical management of COVID-19 [37] . At the same time, the rapidly emerging clinical data require ongoing scrutiny to understand not only the risks and benefits of single drugs to tackle COVID-19, but also the interaction with pharmacological agents commonly used in people with obesity and related NCDs, including type 2 diabetes and cardiovascular diseases, who are especially at risk of or hospitalized with SARS-CoV-2 infection.
cord-290551-a02tueuu	2020	title: Impact of Obesity on Outcomes of Patients with COVID-19 in United States: A Multicenter Electronic Health Records Network Study. We performed a retrospective cohort study using TriNetX (Cambridge, MA, USA), a global federated health research network that provided access to electronic medical records of patients from multiple large member healthcare organizations (HCOs) in United States. Our study using a large nationally representative database showed that COVID-19 patients with any degree of obesity had a significantly higher risk of hospitalization and intubation or death compared to patients without obesity. An analysis of a larger group of selected patients using diagnostic criteria of obesity as any time before the index event (after PSM n=9769) showed a higher risk for composite outcomes in the obesity group ( J o u r n a l P r e -p r o o f
cord-291627-5dqwyd9r	2020	11 Many recent studies are now reporting obesity as one of the risk factors for severity of COVID-19 in USA, Brazil, UK, Italy, Spain and France [12] [13] [14] [15] [16] [17] [18] 67 (summarised in the In the current scenario, since USA has become the epi-centre of the COVID-19 pandemic; the dynamics of patient characteristics in terms of associated complications is showing a difference from the initial data put out by China. During the present pandemic, till now, it has been well established that cardiovascular diseases and diabetes are the major risk factors for poor outcomes but considering a higher BMI to be a forerunner for both these co-morbidities, the inclusion of obesity and overweight individuals as candidates for poor COVID-19 outcomes becomes very important. 58 Thus, the interaction between ACE2-RAS system, adipose tissue and the SARS-CoV-2 could, at least partially, explain the higher morbidity and mortality risk of COVID-19 in obese patients.
cord-300991-ipy24zxp	2020	Through a recent upsurge of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic, the clinical assessment of most of the coronavirus disease 19 (COVID-19) patients clearly presents a health condition with the loss of oro-naso-sensory (ONS) perception, responsible for the detection of flavor and savor. Hence, obesity represents a great risk factor for SARS-CoV-2 infection, as it may hide the viral-associated altered ONS symptoms, thus leading to a high mortality rate in these subjects. Moreover, the number of immunosuppressive T-regulatory, Treg (CD4 + CD25 + Foxp3 + ) cells and concentrations of IL-6, IL-10, and C-reactive protein (CRP) were upregulated in patients with severe COVID-19 [18] , suggesting that SARS-CoV-2 infection may lead to "over-immunosuppression" in the case of obesity ( Figure 1 ). SARS-CoV-2 infection may further aggravate the ONS functions; mask the obesity-induced inflammation, including loss of taste and smell; and render the obese subjects more vulnerable and prone to severe pathophysiological consequences such as RTI, leading to death.
cord-301423-stod75j2	2020	DESIGN: We reviewed how the pandemic adversely influences many of these behaviors, specifically physical activity, sedentary behaviors, sleep, and dietary intakes, and provided individual level strategies that may be used to mitigate them. Sheltering-in-place has significantly altered health behaviours and the food environment by limiting opportunities for daily physical activities, encouraging screen time and sedentary behaviours, disturbing sleep and promoting consumption of ultraprocessed foods and alcohol. The average American adult spends 7·2-9·5 h/d engaged in sedentary behaviours, such as sitting while working, Higher alcohol intake Fig. 1 (colour online) Interrelationships of behavioural risk factors for weight gain that have been affected by the COVID pandemic; the confluence of these behavioural changes is hypothesised to exacerbate the national prevalence of obesity that is a threat for disease severity and mortality reading, watching television and using computers, smartphones or other devices (9) .
cord-301833-q8jiep32	2020	Nine studies (two prospective cohorts, four retrospective cohorts and three cross-sectional) were included and assessed the relationship between obesity and COVID-19 prognosis. Most of the included studies showed some degree of association to: (a) higher BMI and worse clinical presentation and (b) obesity and need of hospitalization. Based on limited methodological quality studies, obesity seems to predict poor clinical evolution in patients with COVID-19. Herein, we perform a systematic review in order to evaluate if overweight and obesity may predict poor outcome in patients with COVID-19. We reviewed data from 17,568 patients with SARS-CoV-2 infection, included in nine studies. Most of these studies highlighted some level of association between obesity and disease severity, encompassing hospitalization rate, admission to ICU, invasive ventilation need and mortality. Once younger patients generally do not represent higher risk for a severe presentation of COVID-19, authors suggest that obesity may be an unrecognized risk factor for hospital care.
cord-311535-ppkwd1kp	2020	The production of increased amounts of cytokines such as TNFα, IL-1, IL-6, and monocyte chemoattractant protein (MCP-1) lead to oxidative stress and defective function of innate and adaptive immunity, whereas the activation of NOD-like receptor family pyrin domain containing 3 (NLRP3) inflammasome seems to play a crucial role in the pathogenesis of the infection. Endothelial dysfunction and arterial stiffness could favor the recently discovered infection of the endothelium by SARS-CoV-2, whereas alterations in cardiac structure and function and the prothrombotic microenvironment in obesity could provide a link for the increased cardiovascular events in these patients. Chronic inflammation and oxidative stress, hypercytokinemia, immune dysregulation, endothelial dysfunction, and cardiovascular abnormalities are all possible mechanisms through which the excess in adipose tissue could lead to the acute hyperinflammatory state that characterizes severe SARS-CoV-2 infections and is responsible for its complications.
cord-316260-1t3ifsfi	2020	In severe acute respiratory syndrome coronavirus 2 infection, these organic changes from obesity may increase the need for ventilatory assistance, risk of thromboembolism, reduced glomerular filtration rate, changes in the innate and adaptive immune response, and perpetuation of the chronic inflammatory response. 3--6 The present review aims to identify the factors that contribute to the increase in the susceptibility and severity of COVID-19 in obese children and adolescents, and its health consequences, to collaborate for better clinical care of these patients. The three main risk factors that link obesity to COVID-19 demonstrated for adults 52 are also present among children and adolescents: chronic subclinical inflammation, impaired immune response, and underlying cardiorespiratory diseases. In conclusion, obesity in childhood and adolescence can be considered a risk factor for greater susceptibility and severity of COVID-19 and is associated with nutritional, cardiac, respiratory, renal, and immunological alterations, which may potentiate the complications of SARS-CoV-2 infection.
cord-318391-2s0rjfn8	2020	A study to assess the effects of lockdown during COVID-19 epidemic on lifestyle in patients with type 2 diabetes in north India reported carbohydrate consumption and frequency of snacking increased in 21% and 23% of study participants, respectively, while exercise duration decreased in 42% and weight gain was documented in 23% of patients [14] . Furthermore, obesity class I (BMI>30 kg/m2) and obesity class II (BMI>35 kg/m2) have been associated with an increased risk for need of invasive mechanical ventilation in patients hospitalized for COVID-19, independent of age, sex, diabetes mellitus and hypertension [9, 13] . A study from China reported similar findings, noting the association of obesity with high mortality risk in young patients with COVID-19 [3] . Data from England reported that patients with type 1 or type 2 diabetes were at increased risk for COVID-19 associated mortality, and there was a U-shaped relationship with BMI. Obesity is clearly a pivotal risk factor associated with severe disease -including greater rate of hospital admission, ICU admission, need for ventilation and excess mortality.
cord-319580-awtp0mpg	2020	The synergistic effects of obesity‐associated delays in immune control of COVID‐19 with mechanical stress of increased adipose tissue may contribute to a greater risk of pulmonary compromise in obese pregnant women. The expression of ACE2 by adipocytes and immune cells also suggests the possibility that adipose tissue may represent a potential reservoir for viral infection and may lead to increased viral burden or persistence; however, no studies to date have demonstrated that adipocytes can be directly infected with SARS-CoV-2. Maternal obesity has emerged as a key risk factor increasing susceptibility of pregnant women to severe COVID-19 disease. There is also an urgent need to focus research on how risk factors, like obesity, alter the immune response to SARS-CoV-2 and influence disease pathogenesis of COVID-19 (Box 1). What is the mechanism of increased risk for severe COVID-19 disease in obese nonpregnant and pregnant women?
cord-321997-3dkl6iha	2020	title: Obesity as a risk factor for greater severity of COVID-19 in patients with metabolic associated fatty liver disease Not only, NASH and NAFLD are important predictive factors for the outcomes in acute and chronic disease processes but also the obesity surgery and its complications [7] . We believe more powerful studies are needed to confirm why obesity is a risk factor for critical illness and or mortality in Covid-19. Obesity as a risk factor for greater severity of COVID-19 in patients with metabolic associated fatty liver disease Effect of Body Mass Index, Metabolic Health and Adipose Tissue Inflammation on the Severity of Non-alcoholic Fatty Liver Disease in Bariatric Surgical Patients: a Prospective Study Effects of Laparoscopic Sleeve Gastrectomy on Non-Alcoholic Steatohepatitis and Liver Fibrosis in Japanese Patients with Severe Obesity Anand U 3 .Non-alcoholic Fatty Liver Disease: Growing Burden, Adverse Outcomes and Associations Nonalcoholic Steatohepatitis Is Associated With Increased Mortality in Obese Patients Undergoing Bariatric Surgery Risk of COVID-19 for patients with obesity
cord-325055-todb1d4x	2020	Furthermore, obesity is increasingly considered as a yet another risk factor, particularly, because it has been observed that people suffering from excessive body weight may experience a more severe course of COVID‐19 infection. Although the data regarding the impact of SARS-CoV-2 in individuals with obesity are limited and their association has not been fully defined yet, it has been observed that people suffering from excessive body weight may experience a more serious COVID-19 infection. 68 Whether the obesity paradox will be present among COVID-19 patients remains to be seen, nevertheless, the phenomenon was reported among other respiratory diseases, such as COPD or ARDS. 53, 69 Its pathophysiological basis remains unknown; however, an increased BMI seems to be associated with a better survival and a slower decline in the lung function in patients with a mild course of chronic obstructive pulmonary disease. Obesity as a risk factor for greater severity of COVID-19 in patients with metabolic associated fatty liver disease Association of obesity with disease severity among patients with COVID-19.
cord-325138-riu4jdc2	2020	29 Specific federal programs which "serve as critical supports for the physical and mental health and academic competence of children " are SNAP, WIC, Child and Adult Care Food Program, School breakfast and lunch program, and the Summer Food Service Program 26 Food programs like these are opportunities to provide healthy food for children most at risk for food insecurity and obesity. WIC provides federal grants to states for supplemental foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and nonbreastfeeding postpartum women, and to infants and children up to age five who are found to be at nutritional risk. Making WIC widely accessible to families hit hard by COVID-19 is crucial because WIC has been shown to both reduce the prevalence of food insecurity 42, 43 and obesity 44 and is an important contributor to early childhood health.
cord-329308-ipui7lo6	2020	During the COVID-19 pandemic, people have tended to gain weight because of environmental factors imposed by quarantine policies, such as decreased physical activity and increased consumption of unhealthy food. The common medications used to treat people with obesity, such as glucagon-like peptide-1 analogues, statins, and antiplatelets agents, should be continued because these agents have anti-inflammatory properties and play protective roles against cardiovascular and all-cause mortality. 54 A cumulative effect of chronic inflammation and hypercytokinemia seems to bring about a hyperinflammatory response through macrophage active syndrome, especially in patients with severe COVID-19 (Fig. 2) . Letter to the Editor: obesity as a risk factor for greater severity of COVID-19 in patients with metabolic associated fatty liver disease Letter to the Editor: obesity as a risk factor for greater severity of COVID-19 in patients with metabolic associated fatty liver disease
cord-333368-kjrk8nn9	2020	While obesity and diabetes may complicate the delivery of supportive care in critical illness regardless of the underlying disease, lessons learned from the interaction of obesity with other systemic inflammatory syndromes suggest that obesity modifies biologic factors related to SARS-CoV-2 infection and the COVID-19 syndrome. In seasonal and pandemic influenza, however, obese individuals may be more susceptible to severe viral respiratory disease even if they mount a serologic response to vaccination 25 A c c e p t e d M a n u s c r i p t 11 Along with possible impairments in pathogen clearance, obese hosts are more likely to experience the breakdown of respiratory epithelium during a pulmonary infection, which leads to increased fluid in the airway space.
cord-338317-ro041w5l	2020	Thus, the association of obesity with worse 105 outcomes in acute lung infection or widespread alveolar damage of other types, appears to be 106 strongest and most consistent with COVID-19 and pandemic H1N1 influenza. In addition to being lower in obesity and most insulin 168 resistant states it is worth noting that adiponectin levels have been reported to be significantly 169 lower in many of the COVID-19 "at risk" groups e.g. Male < Females 20 and South Asians < White 170 is secreted from adipose tissue, associated with insulin resistance and likely contributes to 197 thrombotic risk in obesity by impairing fibrinolysis 23 . In summary, we have applied insights into the pathophysiology of the adverse consequences of 279 obesity and emerging evidence regarding the pathological mechanisms in COVID-19 to suggest 280 possible routes whereby obesity can exacerbate the tissue damage associated with infection by the 281 SARS-CoV-2 virus.
cord-344614-5zcylf6k	2020	Partial least square regression analysis showed that BMI, age and CRP at admission were related to longer length of hospital stay, and time for negative swab. Our study shows that obesity is associated with a severer respiratory presentation of COVID-19 and severer elevation of inflammatory markers, likely leading to higher oxygen demands at admission, prolonged oxygen requirement during hospitalization, delayed viral clearance and extended hospital stay. For this reason, beyond the potential impact on the lung mechanics, obesity might influence the clinical presentation and evolution of SARS-COV-2 infection through J o u r n a l P r e -p r o o f exacerbation of the immune-inflammatory response related to the disease, as confirmed by the increased levels of several inflammatory markers detected in the peripheral blood of patients with obesity in our population.
cord-351223-nnuoadh6	2020	[1] [2] [3] [4] [5] [6] [7] Early reports from Chinese series identified hypertension, diabetes, chronic pulmonary disease, and cardiovascular disease as the comorbidities most consistently associated with hospitalization, respiratory support, intensive care unit (ICU) admission, and death in COVID-19 patients. Subsequent reports from the United States and Europe suggested that patients with a higher body mass index (BMI) are at greater risk for hospital admission and severe disease requiring respiratory support. Secondary analyses included assessing the association of BMI group with oxygen requirement upon hospital admission, length of stay, ICU admission at any point, and mechanical ventilation at any point. Our study shows that amongst hospitalized patients with COVID-19 infection, obesity was significantly associated with mortality after adjusting for age, gender, and other comorbidities. This finding provides further evidence that obesity is a key comorbidity in COVID-19 that may not only predict severe disease requiring hospital admission, oxygen supplementation, or mechanical ventilation, but may also predict increased mortality.
cord-354805-5wnp02wd	2020	We have read with great interest the prospective cohort study published by Czernichow et al (1), wherein they found that obesity doubles mortality in patients hospitalized with coronavirus disease (COVID‐19), using as an indicator anthropometric, the body mass index (BMI). We have read with great interest the prospective cohort study published by Czernichow et al 1 , wherein they found that obesity doubles mortality in patients hospitalized with coronavirus disease (COVID-19), using as an indicator anthropometric, the body mass index (BMI). Excess mortality and severity of the COVID-19 disease in people with obesity is also prevalent in developing countries with constrained resources such as Peru, in which preliminary findings reported by the Ministry of Health show that among people with obesity died from COVID-19, 85.5% had obesity as assessed by BMI. 6 As studies have highlighted the association between this disease and its mortality and severity of SARS-CoV-2 infection, Peru and other countries are recognizing the importance of considering obesity as a disease and developing effective health system strategies and public health approaches.
cord-354928-brliql4d	2020	CONCLUSION: Overweight and obesity were independent risk factors of severe illness in COVID‐19 patients. Old age and comorbidities, such as hypertension, diabetes, and chronic respiratory disease, were identified as risk factors of poor outcomes for COVID-19 patients according previous studies (3, 4) . Obesity was regarded as a common risk factor to aggravate the severity of respiratory diseases, which was associated with poor prognosis in influenza A (H1N1) pulmonary infection (5, 6) . A retrospective study enrolled 124 COVID-19 patients who were admitted to intensive care unit (ICU) showed more patients required invasive mechanical ventilation (IMV) therapy with increased body mass index (BMI) (12) . Several studies have demonstrated that the presence of type 2 diabetes was a significant risk factor of severe illness and fatal outcome of COVID-19 (24) (25) (26) .