Understanding the Co-Epidemic of Obesity and COVID-19: Current Evidence, Comparison with Previous Epidemics, Mechanisms, and Preventive and Therapeutic Perspectives

Abstract

Purpose of review: A growing body of evidence suggests that obesity and increased visceral adiposity are strongly and independently linked to adverse outcomes and death due to COVID-19. This review summarizes current epidemiologic data, highlights pathogenetic mechanisms on the association between excess body weight and COVID-19, compares data from previous pandemics, discusses why COVID-19 challenges the "obesity paradox," and presents implications in prevention and treatment as well as future perspectives.

Recent findings: Data from meta-analyses based on recent observational studies have indicated that obesity increases the risks of infection from SARS-CoV-2, severe infection and hospitalization, admission to the ICU and need of invasive mechanical ventilation (IMV), and the risk of mortality, particularly in severe obesity. The risks of IMV and mortality associated with obesity are accentuated in younger individuals (age ≤ 50 years old). The meta-inflammation in obesity intersects with and exacerbates underlying pathogenetic mechanisms in COVID-19 through the following mechanisms and factors: (i) impaired innate and adaptive immune responses; (ii) chronic inflammation and oxidative stress; (iii) endothelial dysfunction, hypercoagulability, and aberrant activation of the complement; (iv) overactivation of the renin-angiotensin-aldosterone system; (v) overexpression of the angiotensin-converting enzyme 2 receptor in the adipose tissue; (vi) associated cardiometabolic comorbidities; (vii) vitamin D deficiency; (viii) gut dysbiosis; and (ix) mechanical and psychological issues. Mechanistic and large epidemiologic studies using big data sources with omics data exploring genetic determinants of risk and disease severity as well as large randomized controlled trials (RCTs) are necessary to shed light on the pathways connecting chronic subclinical inflammation/meta-inflammation with adverse COVID-19 outcomes and establish the ideal preventive and therapeutic approaches for patients with obesity.

Keywords: Body mass index; COVID-19; Cytokine storm; Diabetes; Infection; Inflammation; Influenza; Obesity; Pandemic; SARS-CoV-2; Therapy.

Fig. 1

Underlying pathophysiologic mechanisms and factors linking obesity to severe COVID-19. ACE2, angiotensin-converting enzyme 2; CHD, coronary heart disease; eNOS, endothelial nitric oxide synthase; GERD, gastro-esophageal reflux disease; HTN, hypertension; IFN, interferon; IL, Interleukin; IMV, invasive mechanical ventilation; MAFLD, metabolic associated fatty liver disease; MCP-1, monocyte chemoattractant protein-1; Mets, metabolic syndrome; NK, natural killer; NLRP3, NOD-like receptor family pyrin domain containing 3; NO, nitric oxide; PAI-1, plasminogen activator inhibitor-1; RAAS, renin-angiotensin-aldosterone system; T2DM, type 2 diabetes mellitus; TNF-α, tumor necrosis factor-α; Tregs, regulatory T cell. (All images are derived from the free medical site http://smart.servier.com/ by Servier licensed under a Creative Commons Attribution 3.0 Unported License)