key: cord-0805953-ztv9vfvx authors: Townsend, Matthew J.; Kyle, Theodore K.; Stanford, Fatima C. title: Commentary: COVID-19 and Obesity: Exploring Biologic Vulnerabilities, Structural Disparities, and Weight Stigma date: 2020-07-14 journal: Metabolism DOI: 10.1016/j.metabol.2020.154316 sha: 386cec1e00ad5506ea64db04405c7b87cd5e2274 doc_id: 805953 cord_uid: ztv9vfvx nan J o u r n a l P r e -p r o o f 3 more likely to be viewed as non-adherent to prescribed treatments [37] . Increased BMI has been associated with decreased utilization of healthcare, including lower rates of routine breast and gynecologic cancer screening exams as well as delays in presentation for care [38] . Researchers have reported 32% of women with obesity and 55% of women with severe obesity endorsed cancelling or delaying medical appointment(s) due to weight concerns [39] . These patterns have been measured most frequently in primary care but likely extend to other healthcare settings. A recent expert joint consensus statement highlights the wide-reaching harms of weight bias and historical shortcomings of related public health efforts [34] . The implications of weight stigma are particularly alarming in the context of COVID-19. Observed decreases in non-COVID hospitalizations indicate a general reluctance to seek even necessary medical care during this pandemic [40] . Individuals with obesity are especially likely to delay care, or avoid it completely, because of bias and humiliation experienced in healthcare settings [38] . As government guidance [10, 41, 42] and news sources [43-46] highlight obesity as a risk factor for severe COVID-19, people with obesity may differentially seek care due to heightened stigma or perceived personal vulnerability. When limiting transmission is a public health priority and delays in care can be deadly, it is more important than ever to understand and address how weight status affects who is (not) presenting for care. This knowledge is vital as numerous regions in the United States and around the world continue to suffer an initial peak in infections and hospitalizations, and as others brace for an anticipated second wave. How medical stigma translates to inpatient COVID-19 care is unclear. We appreciate the concern raised that patients with stigmatized medical conditions, such as substance use disorder, are not prioritized if scarce medical resources need to be rationed [47] . Providers may alternatively expedite intensive care and other available treatments for patients with obesity Weight stigma and its cumulative sequelae are a prevalent and distinct vulnerability that interacts with biologic and structural risks for worse COVID-19 outcomes. Healthcare avoidance may act synergistically with any underlying biologic susceptibilities to critical illness and mortality among people with obesity. This point has been neglected in lay media and medical journals. The deleterious effect of weight bias falls disproportionately on the minority and socioeconomically disadvantaged groups most affected by obesity, structural barriers to health, racism, and other forms of discrimination. It therefore exacerbates inequities now painfully evident in COVID-19 cases and mortality. We identify three necessary responses. First, further research is needed to quantify the impact of healthcare avoidance for COVID-and non-COVID-related medical needs. Patients with stigmatized medical conditions like obesity are at particular risk. Time from symptoms to presentation is one important measure of delayed care which has not entered published models of obesity, comorbidities, and COVID-19. Preliminary analyses of obesity and its comorbidities as risk factors for COVID-19 would also benefit from more comprehensive research integrating data on race, ethnicity, and socioeconomic disadvantage. The United Kingdom Office for National Statistics has included local area deprivation, educational attainment, and other census data in analyses of ethnic group differences in COVID-19 deaths [31] ; a similar approach could be applied to investigations of obesity and COVID-19 outcomes. Inclusion of these variables may help parse biologic, structural, and stigmatic effects of obesity on outcomes. Second, in words and actions, we must actively affirm the dignity of our patients. This is always important but perhaps most so at a time of heightened fear and uncertainty. Evidence-J o u r n a l P r e -p r o o f based risk communication must avoid reducing individuals to their medical conditions; respectful language ("person with obesity" rather than "obese person") humanizes our patients [48] . Stigma can be uncomfortable to acknowledge and difficult to measure and address, but these difficulties do not diminish its significance. Where possible, we must identify and call out explicit and implicit bias in clinical settings. Stereotypes such as non-adherence or impulsiveness should be questioned. Weight-related humor has no place in healthcare. Third, we must assess opportunities to redefine care. Telehealth has soared to minimize infectious exposures [49] . Virtual visits and digital health tools may be options for patients with obesity to receive care with less perceived stigma than during traditional in-person encounters. Though complex, direct measurement of perceived stigma and other psychological burdens during the pandemic can expose shortcomings of current practice and opportunities for patient support. People with obesity are faced with a challenging set of overlapping vulnerabilities in the COVID-19 pandemic. 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