key: cord-0951936-yzn3ym65
authors: Raeisi, Tahereh; Mozaffari, Hadis; Sepehri, Nazaninzahra; Darand, Mina; Razi, Bahman; Garousi, Nazila; Alizadeh, Mohammad; Alizadeh, Shahab
title: The negative impact of obesity on the occurrence and prognosis of the 2019 novel coronavirus (COVID-19) disease: a systematic review and meta-analysis
date: 2021-07-11
journal: Eat Weight Disord
DOI: 10.1007/s40519-021-01269-3
sha: f9cb88b79cd78124d9b270106acda6408163043d
doc_id: 951936
cord_uid: yzn3ym65

PURPOSE: The 2019 novel coronavirus (COVID-19) is an emerging pandemic, with a disease course varying from asymptomatic infection to critical disease resulting to death. Recognition of prognostic factors is essential because of its growing prevalence and high clinical costs. This meta-analysis aimed to evaluate the global prevalence of obesity in COVID-19 patients and to investigate whether obesity is a risk factor for the COVID-19, COVID-19 severity, and its poor clinical outcomes including hospitalization, intensive care unit (ICU) admission, need for mechanical ventilation, and mortality. METHODS: The study protocol was registered in PROSPERO (CRD42020203386). A systematic search of Scopus, Medline, and Web of Sciences was conducted from 31 December 2019 to 1 June 2020 to find pertinent studies. After selection, 54 studies from 10 different countries were included in the quantitative analyses. Pooled odds ratios (OR) with 95% confidence intervals (CIs) were calculated to assess the associations. RESULTS: The prevalence of obesity was 33% (95% CI 30.0%–35.0%) among patients with COVID-19. Obesity was significantly associated with susceptibility to COVID-19 (OR = 2.42, 95% CI 1.58–3.70; moderate certainty) and COVID-19 severity (OR = 1.62, 95% CI 1.48–1.76; low certainty). Furthermore, obesity was a significant risk factor for hospitalization (OR = 1.75, 95% CI 1.47–2.09; very low certainty), mechanical ventilation (OR = 2.24, 95% CI 1.70–2.94; low certainty), intensive care unit (ICU) admission (OR = 1.75, 95% CI 1.38–2.22; low certainty), and death (OR = 1.23, 95% CI 1.06–1.41; low certainty) in COVID-19 patients. In the subgroup analyses, these associations were supported by the majority of subgroups. CONCLUSION: Obesity is associated with COVID-19, need for hospitalization, mechanical ventilation, ICU admission, and death due to COVID-19. LEVEL OF EVIDENCE: Level I, systematic reviews and meta-analyses. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40519-021-01269-3.

The 2019 novel coronavirus , caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), is a viral disease which first diagnosed in late 2019 in Wuhan City of Hubei Province of China, and it is spreading rapidly [1] . Currently, the prevalence of COVID-19 has turned into one of the most critical public health concerns [2] . Recent evidence suggests that the severity of clinical manifestations and mortality rate of the disease varies from person to person and depends on a variety of factors [3] . Given this, the identification of prognostic factors related to COVID-19 and its poor clinical outcomes is urgent to distinguish populations at higher risk for the disease and to better prevention and early treatment of the disease. Since obesity is associated with a mild chronic inflammatory condition [4] and immune dysfunction [5] , evidence suggests that obesity may be a risk factor [6] , but the findings are still insufficient in this regard. In a single center in France, 75% of individuals with SARS-CoV-2 infections admitted to the intensive care unit (ICU) had a body mass index (BMI) > 30 kg/m 2 . This study showed that with increasing BMI, the severity of the disease and the proportion of patients who need mechanical ventilation increase but no difference in mortality rates was observed between obese and non-obese patients [7] . Findings in Italy revealed that the need for intensive care and the use of a ventilator in overweight and obese patients, despite their younger age, is higher than in normal weight patients [8] . A cross-sectional study in Mexico demonstrated that obesity is one of the most critical risk factors for coronavirus respiratory infection [9] . In contrast, Wu et al. did not considered a statistically significant relationship between obesity and the severity of COVID-19 [10] .

Heterogeneous findings may be due to low statistical power, small sample size, unified ethnicity, and differences in age and adjustment level for covariates in individual studies. To date, some meta-analyses [11] [12] [13] [14] have attempted to summarize available evidence regarding the relation of obesity to COVID-19 outcomes. Nevertheless, the preliminary meta-analyses included small number of studies, did not comprehensively assess related clinical outcomes, did not assess the influence of potential effect modifiers, such as confounder factors, age, ethnicity and study design, or were conducted on Chinese populations, and thus, were not generalizable to other populations. The current systematic review and meta-analysis study aimed to comprehensively investigate the global prevalence of obesity in patients with COVID-19 and the relation of obesity to COVID-19, COVID-19 severity, and its poor clinical outcomes including hospitalization, ICU admission, need for mechanical ventilation, and mortality.

This study was performed in a stepwise process in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) [15] . The protocol of this study is registered in PROSPERO (ID: CRD42020203386). This article does not contain any studies with human participants performed by any of the authors.

An exhaustive systematic search was conducted by multiple researchers through electronic databases (Scopus, Medline, Web of Sciences) retrieving all potential publications, published from 31 December 2019 to 1 June 2020, investigating the prevalence of obesity among COVID-19 patients or the association of obesity with the risk of COVID-19, COVID-19 severity, death, ICU admission, need for mechanical ventilation, and hospitalization due to COVID-19. The combination of key words was as follows: ("obese" OR "obesity" OR "overweight" OR "body mass index" OR "BMI" OR "adiposity" OR "adipose" OR "body size" OR "weight") AND ("COVID-19" OR "2019 novel Coronavirus" OR "2019-nCoV" OR "SARS-CoV-2" OR "coronavirus 2019"). No restriction filter was applied for primary search and if required, Google translate was used to translate the data into English. Moreover, cross-references within both eligible and review articles were carried out for feasible additional publications.

The retrieval publications were screened and abstracted if they met the following inclusion criteria: (a) Observational studies (cohort, case-control, cross-sectional, case series); (b) Studies providing sufficient information for the calculation of relative risk (RR) and/or odds ratio (OR), in cases which critical data were not reported in the eligible articles, we contacted authors; (c) Studies reporting the prevalence of obesity in COVID-19 patients (primary outcome) and/ or data on the association between obesity and following secondary outcomes: COVID-19 and COVID-19 severity (severe COVID-19 was defined based on international guidelines or hospitalization, ICU (Intensive Care Unit) admission, need for mechanical ventilator, mortality due to COVID-19 or a combination of these) [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] . Duplicates, case reports, reviews, studies with insufficient data after contacting with authors, and abstracts were all excluded, but letters were included. It is worth mentioning that all processes of data extraction were performed by two independent investigators, they verified the validity of extracted data, any potential disagreements were resolved by discussion or, where necessary, by a third investigator.

All required data were extracted conforming to the standardized extraction checklist for the following data: the first author's name, journal and year of publication, variables adjusted for, country of origin, ethnicity, mean, median or range of age, and odds ratio (OR) and corresponding confidence interval (CI) for outcomes. Moreover, Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to assess the overall quality of the evidence in each pooled analysis [26] .

In the current study, odds ratios (ORs) were used to estimate the association of obesity with outcomes. The potential between study heterogeneity was estimated by Cochran's Q-statistic (P value < 0.10 was considered as statistically significant) and I-squared (I 2 ) tests. Because of a remarkable evidence for heterogeneity, the random-effected model was applied [27, 28] . To assessed the predefined sources of heterogeneity among included studies, subgroup analysis based on obesity severity, study design (cohort vs. noncohort), ethnicity (Caucasian vs. East-Asian), age category (≥ 50 years vs. ˂ 50 years), and adjustment for covariates (Adjusted vs. Non-adjusted effect size) and univariate random effects meta-regressions based on sex and age of participants were used. Additionally, in sensitivity analysis, we evaluated the conclusiveness and robustness of results by excluding each of the studies from the pooled estimate and analyzing the rest of them. This method enables the assessment of whether the pooled estimates were affected by any individual studies. To discover the risk of publication bias and the small-study effect, Begg's funnel plots and Egger's regression test were estimated (P value < 0.05 was considered as statistically significant) [29, 30] . The funnel plot asymmetry was interpreted as follow: in case of no evidence of publication bias, studies with high precision (large study effects) will be located near the average line, and studies with low precision (small-study effects) will be spread equally on both sides of the average line; any deviation from this shape can indicate publication bias. In the forest plot figures, the areas of the squares for individual studies or diamond-shaped for overall results are inversely proportional to the variances of the log odds ratio estimates, and horizontal lines display CIs. The data analyses were carried out using STATA (version 14.0; Stata Corporation, College Station, TX) and SPSS (version 23.0; SPSS, Inc. Chicago, IL) software.

We identified 956 studies from our preliminary systematic search and four additional records through reference list searching. Of the 960 studies, 54 studies [8, 9, [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] were eventually eligible to be included in the metaanalysis (Fig. 1) ; some studies reported data on > 1 pertinent outcome. Of these, there were 52 studies reporting results on obesity prevalence among patients with COVID-19 involving a total of 504,556 cases [8, 9, [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] and data regarding the secondary outcomes were reported in 43 studies [8, 9, 16-25, 31, 32, 34-38, 42, 43, 45-55, 57-61, 64, 67, 68, 70-72] . A study by Chao et al. [73] was exclusively performed on children and thus was not included in the meta-analysis. Included publications were all observational in nature, published in 2020. The number of COVID-19 participants varied between 16 and 387,109 cases. Participants were from two ethnicities (Caucasian and East-Asian) from 10 different countries, including Mexico, United Kingdom (UK), Italy, United States of America (USA), France, China, Bolivia, Spain, Germany, and Singapore. Further characteristics of included studies are presented in Table 1 .

Main pooled estimates are summarized in Table 2 , and corresponding plots are provided in the Additional file 1. Metaanalysis indicated that the prevalence of obesity was 33% among individuals with COVID-19 (prevalence estimate 33.0%; 95% CI 30.0%-35.0%). Moreover, not only obesity was associated with increased risk of COVID-19 (OR = 2.42, 95% CI 1.58-3.70), but it also was associated with greater risk for disease severity (OR = 1.62, 95% CI 1. 48 Table 2 ). There was significant evidence for heterogeneity across studies in all analyses ( Table 2) . Metaregression showed that the relationships between obesity and all outcomes were not affected by sex and age.

Subgroup analyses have been provided in the Additional file 1. Findings indicate that the relationship between obesity and the occurrence of COVID-19 was independent of study design, the age category of participants, and the level of adjustment for covariates. Nevertheless, this association was not supported in different categories of obesity severity due to the small number of the analyzed studies for each category. Notably, the association of obesity with COVID-19 severity and hospitalization was supported by all subgroups. For mechanical ventilation, the relationship was significant in all subgroups except for patients with Class I/ Sever obesity (2 studies), East-Asians (1 study), and patients with age < 50 years (3 studies). For ICU admission, the relationship was significant in all subgroups except for patients with Class I obesity (3 studies) and East-Asians (1 study). Moreover, for death, the findings were supported in cohort studies, patients with Caucasian ethnicity, patients with age < 50 years, and in studies with adjusted effect sizes.

In the sensitivity analysis of studies on the relation of obesity to COVID-19 susceptibility and COVID-19 severity, no individual study significantly affected the pooled effect size, showing the reliability of the results. The pooled effect size ranged from 1.83 (95% CI 1.44-2.33) to 2.61 (95% CI 1.64-4.14) for studies on COVID-19 (Additional file 1) and ranged from 1.83 (95% CI 1.44-2.33) to 2.61 (95% CI 1.64-4.14) for COVID-19 severity (Additional file 1).

Egger test revealed no evidence of publication bias for any of the outcomes except COVID-19 severity (t = 2.12, P = 0.04), hospitalization (t = 2.48, P = 0.04), and need for mechanical ventilation (t = 6.50, P = 0.001) (Additional file 1). 

The current meta-analysis showed that the prevalence of obesity was 33% among individuals with COVID-19. Not only was obesity associated with increased occurrence of COVID-19, but it was also associated with greater odds of developing critical conditions (e.g. hospitalization, mechanical ventilation, ICU admission), and mortality. Notably, these associations were consistently observed among Caucasians. To the best of our knowledge, this is the first study that has provided a comprehensive evaluation of both occurrence and prognosis of COVID-19 in relation to obesity. The 33% prevalence of obesity among patients with COVID-19 corroborates a recent review that has shown obesity is the most prevalent comorbidity among patients with severe or fatal COVID-19 (42%) [12] . Similar observations have been reported in other respiratory-related outbreaks including MERS-CoV [74] , influenza [75] , and SARS-CoV [76] . Moreover, the positive association of obesity with the occurrence and severity of COVID-19 is in line with similar reviews that only included initial studies from China [14] .

In the current study, obesity was associated with poor prognosis of COVID-19 by increasing the need for hospitalization, mechanical ventilation, ICU admission, and even mortality. This finding was in the line with a current systematic review that included mostly case report, case series, letter to editor, and comments [77] . That review found that obesity was associated with the increasing prevalence of hospitalization (average of 20.4%) and greater lethality (average of 20.4%) in the patient with COVID-19 [77] . The contribution of obesity to diseases severity and the requirement of advanced medical care in COVID-19 has been also stated in another initial review that only included three studies [78] . Our study also further added to a meta-analysis by Földi et al. that showed obesity is a risk factor for both ICU admission and mechanical ventilation requirement in COVID-19 patients [11] . Nevertheless, the study by Földi et al. did not investigate the relation of obesity to the risk of mortality, and hospitalization due to COVID-19. This is of particular importance since restricted IUC capacity has created great concern across the world. As such, knowledge of relevant risk factors can help clinicians better identify and guide the high-risk populations for making the most Although the underlying mechanism linking obesity to COVID-19 has remained to be elucidated, several potential pathways may justify this association through chronic inflammation, higher Angiotensin-Converting Enzyme 2 (ACE-2) concentration, and functional restrictive capacity of the lung. Chronic inflammation is accompanied by the increased level of C-reactive protein, interleukin 6, and adipokines, all of which can suppress the immune system and put the body at greater risk for the COVID-19 infection [67, 79] . Moreover, ACE-2 receptors-responsible for facilitating COVD-19 entry into cells-can be expressed in different parts of the body including adipose tissue [80] . That is, greater adiposity is equal to having more ACE-2 receptors and subsequently be more susceptible to catch COVID-19. Finally, individuals with obesity have physiological respiratory dysfunction which can increase the risk for hypoventilation [81] , and thus may contribute to a worse prognosis of COVID-19.

The limitations of this study should be reported. Studies used different criteria to define obesity such that some studies define obesity based on national cut-points (BMI > 25 kg/m 2 ), while others used the WHO definition of obesity (BMI > 30 kg/m 2 ). Also, the included studies did not mention the detailed comorbidities of obese patients, such as diabetes and hypertension. Additionally, although we divided disease severity based on clinical symptoms, ICU care and death, the included studies still varied in their differentiation of patients' disease severity in clinical definition, with classifications of "mild, moderate, severe, and critical", "ordinary and severe/critical", "common and severe", and "non-severe and severe" disease. A high heterogeneity existed between studies; however, subgroup analyses were conducted to trace potential sources. As another limitation, because of the unavailability of data for Africa, data obtained from the studies included in the present meta-analysis were categorized into just two ethnicities (Caucasian and East-Asian), limiting the expandability of our findings to African descent populations. Nonetheless, this is the first study that provided an extensive evaluation of health literature to assess the association of obesity with odds of occurrence and prognosis of COVID-19. This study brings attention to obesity as an important risk factor for COVID-19, which has dire consequences in relation to morbidity, mortality and the financial burden generated by the current pandemic. We followed a rigorous methodology as all stages were conducted by two reviewers independently including study selection, data extraction, and quality appraisal. The large sample size and extensive coverage of different regions around the world will increase the power and representativeness of the results to the whole patient population worldwide.

In conclusion, obesity was associated with the occurrence and poor prognosis of COVID-19. As the main concern is that vaccines might be less effective for obese people [82] , more attention should be paid to prevent and treat COVID-19 in obese patients.

Previous studies have reported that obesity might be related to poor prognosis of COVID-19; however, due to low statistical power, small sample size, heterogeneity of ethnicity, and differences in age and adjustment level for covariate, the results of studies were inconclusive. 

This meta-analysis confirmed that obesity is associated with COVID-19 and its poor clinical outcomes. Thus, it is highly recommended to consider obesity status in prognostic scores and improvement of guidelines for the clinical care of patients with COVID-19 and even for vaccination.

The online version contains supplementary material available at https:// doi. org/ 10. 1007/ s40519-021-01269-3.

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Acknowledgements Each author acknowledges he/she has participated in the work in a substantive way and is prepared to take full responsibility for the work.

Authors' contributions SA and NG designed the study. MA, HM and TR searched, screened and selected the articles. NS, MD, BR and SH extracted the data from the articles. SA and HM performed data analysis and interpretation. TR drafted the manuscript. All authors contributed in writing and editing of the manuscript. SA supervised the study.Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Data availability Data can be reached by contacting the corresponding author.Code availability Not applicable.

Conflict of interest All authors declared that they have no competing interests.Ethical approval Not applicable.

Consent for publication This is formally to submit the article entitled "The negative impact of obesity on the occurrence and prognosis of the 2019 novel coronavirus (COVID-19) disease: a systematic review and meta-analysis" prepared by the Tehran University of Medical Sciences for review and, hopefully, publication in your prestigious journal. The authors would like to advise that all authors listed have contributed to the work. All authors have agreed to submit the manuscript Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity. No part of the work has been published before. There is no conflict of interest in this paper.