key: cord-0831237-6xnpbxqg
authors: Aminian, Ali; Bena, James; Pantalone, Kevin M.; Burguera, Bartolome
title: Association of obesity with postacute sequelae of COVID‐19
date: 2021-06-15
journal: Diabetes Obes Metab
DOI: 10.1111/dom.14454
sha: f240b4130f6967557d2441058ca5cc6c74bc1d95
doc_id: 831237
cord_uid: 6xnpbxqg

Obesity is a major risk factor for the development of severe coronavirus disease 2019 (COVID‐19) infection and mortality. However, it is not known whether patients with obesity are at a greater risk of developing postacute sequelae of COVID‐19 (PASC). In a median follow‐up time of 8 months and counting from 30 days following a positive viral test of 2839 patients who did not require intensive care unit admission and survived the acute phase of COVID‐19, 1230 (43%) patients required medical diagnostic tests, 1255 (44%) patients underwent hospital admission, and 29 (1%) patients died. Compared with patients with a normal body mass index (BMI), the risk of hospital admission was 28% and 30% higher in patients with moderate and severe obesity, respectively. The need for diagnostic tests to assess different medical problems, compared with patients with normal BMI, was 25% and 39% higher in patients with moderate and severe obesity, respectively. The findings of this study suggest that moderate and severe obesity (BMI ≥ 35 kg/m(2)) are associated with a greater risk of PASC.

Emerging data indicate that some coronavirus disease 2019 (COVID-19) survivors experience symptoms beyond the usual recovery time of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. These symptoms and problems, collectively called the postacute sequelae of COVID-19 (PASC), can range from mild to disabling severity and can affect different body organs and systems. [1] [2] [3] [4] Obesity is a major risk factor for development of severe COVID-19 infection and mortality. Obesity, as a proinflammatory and pro-thrombotic disease, can impair the immune system, and is associated with cardiovascular, pulmonary and metabolic disorders that can worsen the outcomes of COVID-19 infection during the acute phase. [5] [6] [7] [8] [9] [10] [11] However, it is not known whether patients with obesity are at a greater risk of developing PASC. Patients who did not have their routine care at CCHS, patients with missing baseline body mass index (BMI) data, a history of organ transplant, active cancer, and current pregnancy at the time of positive testing, and patients who died or required admission to the intensive care unit (ICU) within the first 30 days after the positive viral test, were excluded.

Three prespecified outcomes of interest that occurred 30 days or later after the first positive viral test included hospital admission, allcause mortality, and a composite variable of any diagnostic tests.

These outcomes, which collectively could indicate the presence of PASC, were compared among patients with a BMI of 18.5 to 24.9 T A B L E 1 Baseline characteristics and outcomes by body mass index (BMI) group at 30 or more days Figure 2 ).

Likewise, the need for diagnostic tests to assess cardiac Post hoc pairwise comparisons were performed using Bonferroni adjustment (P < .005).

Diagnostic tests were chosen to serve as proxy for symptoms and disorders related to different body organ systems and included nervous system (computed tomography [CT] and magnetic resonance imaging

[MRI] of brain or spine, electroencephalogram, electromyography and lumbar puncture), cardiac (electrocardiogram, echocardiogram, cardiac stress test, nuclear scan, and catheterization, serum troponin and creatine kinase myocardial band (CKMB)), pulmonary (chest x-ray, CT, pulmonary function test, spirometry and diffusing capacity of the lungs for carbon monoxide (DLCO)), vascular (serum D-dimer, lower extremity duplex scan, lung ventilation-perfusion scan), renal (urine albumin, kidney ultrasound and biopsy), hepatic (antinuclear, antismooth muscle and antimitochondrial antibodies, viral hepatitis panel, liver vascular ultrasound and liver biopsy), gastrointestinal (upper or lower endoscopy, CT of abdomen or pelvis, serum amylase, lipase), endocrine (serum C-peptide, ketons, hydroxybutyric acid, glutamic acid decarboxylase and anti-islet antibody), haematologic (erythrocyte sedimentation rate (ESR), C-reactive protein, blood culture, and bone marrow aspiration and biopsy), and mental health (consult order to psychology or psychiatry). Commonly ordered tests in daily clinical practice including complete blood counts, renal function tests, liver function tests, HbA1c, urinalysis and lipid panel were not considered. Pairwise comparisons if overall comparisons are significant: 1 Significantly different from <25. 2 Significantly different from 25 to 29.9. 3 Significantly different from 30 to 34.9. 4 Significantly different from 35 to 39.9. 5 Significantly different from

Any diagnostic test includes any test ordered across the 10 specific systems.

significantly higher in patients with a BMI of 35 kg/m 2 or higher compared with normal BMI patients in adjusted analysis (Table 2) .

Mortality rates were not significantly different among patients in different BMI groups (P = .83) ( Table 2 , Figures 1 and 2 ). .013

Note: Adjusted for age, sex, race, ethnicity and smoking status. Statistically significant differences are highlighted in bold.

In the Cox models, the overall P value comparing all five BMI groups was calculated and presented. Additionally, normal BMI (18-24.9 kg/m 2 ) was considered as a reference and adjusted hazard ratios with 95% confidence intervals for comparison of other BMI groups with the reference group were estimated. a Any diagnostic test includes any test ordered across the 10 specific systems.

F I G U R E 2 Outcomes stratified by five body mass index (BMI) groups: forest plot displaying adjusted hazard ratio (HR) and 95% confidence interval (CI) for each of the BMI subgroups compared with BMI 18 to 24.9 kg/m 2 as a reference

Four-month clinical status of a cohort of patients after hospitalization for COVID-19

Readmission and death after initial hospital discharge among patients with COVID-19 in a large multihospital system

Sequelae in adults at 6 months after COVID-19 infection

6-month consequences of COVID-19 in patients discharged from hospital: a cohort study

Individuals with obesity and COVID-19: a global perspective on the epidemiology and biological relationships

Global pandemics interconnected -obesity, impaired metabolic health and COVID-19

The J-shaped relationship between body mass index and mortality in patients with COVID-19: a dose-response meta-analysis

Obesity as a driver of international differences in COVID-19 death rates

Relationship between obesity and severe COVID-19 outcomes in patients with type 2 diabetes: results from the CORONADO study

Obesity as a risk factor for COVID-19 mortality in women and men in the UKbiobank: comparisons with influenza/pneumonia and coronary heart disease

Obese COVID-19 patients show more severe pneumonia lesions on CT chest imaging

Association of obesity with postacute sequelae of COVID-19

Clinic for creation of the database. They did not receive compensation for their role in the study.

The authors have no conflicts of interest to declare.

All authors contributed in the concept and design of study, interpretation of data, and critical revision of manuscript. AA and JB contributed

The peer review history for this article is available at https://publons. com/publon/10.1111/dom.14454.

The data that support the findings of this study can be available on a reasonable request from the corresponding author after obtaining the permissions from Cleveland Clinic. The data are not publicly available due to privacy or ethical restrictions.

https://orcid.org/0000-0001-5756-9917Kevin M. Pantalone https://orcid.org/0000-0002-3897-4551