Determining whether ethnic minorities with severe obesity face a disproportionate risk of serious disease and death from COVID-19: outcomes from a Southern California-based retrospective cohort study

Abstract

Objective: Obesity has been recognised as a risk factor for poor outcomes associated with COVID-19. Ethnic minorities with COVID-19 have been independently found to fare poorly. We aim to determine if ethnic minorities with severe obesity-defined as a body mass index (BMI) above 40 kg/m²-experience higher rates of hospitalisation, invasive ventilation and death.

Design and setting: Retrospective cohort study from 1 March 2020 to 28 February 2021 within an integrated healthcare organisation in Southern California.

Participants: We identified 373 831 patients by COVID-19 diagnosis code or positive laboratory test.

Methods: Multivariable Poisson regression with robust error variance estimated adjusted risks of hospitalisation, invasive ventilator use and death within 30 days. Risks were stratified by ethnicity and BMI.

Results: We identified multiple differences in risk of poor outcomes across BMI categories within individual ethnic groups. Hospitalisation risk with a BMI over 45 kg/m² was greater in Asian (RR 2.31, 95% CI 1.53 to 3.49; p<0.001), Hispanic (RR 3.22, 95% CI 2.99 to 3.48; p<0.001) and Pacific Islander (RR 3.79, 95% CI 2.49 to 5.75; p<0.001) patients compared with White (RR 2.04, 95% CI 1.79 to 2.33; p<0.001) and Black (RR 2.00, 95% CI 1.70 to 2.34; p<0.001) patients. A similar trend was observed with invasive ventilation risk. The risk of death was greater in Asian (RR 3.96, 95% CI 1.88 to 8.33; p<0.001), Hispanic (RR 3.03, 95% CI 2.53 to 3.61; p<0.001) and Pacific Islander (RR 4.60, 95% CI 1.42 to 14.92; p=0.011) patients compared with White (RR 1.47, 95% CI 1.13 to 1.91; p=0.005) and Black (RR 2.83, 95% CI 1.99 to 4.02; p<0.001) patients with a BMI over 45 kg/m².

Conclusions: Ethnic minorities with severe obesity, particularly Asian, Hispanic and Pacific Islander patients, had a statistically significant higher risk of hospitalisation, invasive ventilator use and death due to COVID-19. Potential explanations include differences in adipose tissue deposition, overall inflammation and ACE-2 receptor expression.

Keywords: COVID-19; Epidemiology; INFECTIOUS DISEASES; INTERNAL MEDICINE; PRIMARY CARE.

Figure 1

Forest plots of adjusted risk ratios of body mass index for hospitalisation stratified by ethnicity (n=25 970). Models were adjusted for ethnicity, age, gender, income, smoking history, pregnancy, hypertension, heart failure, diabetes, coronary artery disease, atherosclerosis, sleep apnoea, chronic obstructive pulmonary disease, chronic kidney disease, end-stage renal disease, HIV, cerebrovascular disease, chronic liver disease, fatty liver, immunosuppressive treatment and malignancy. BMI, body mass index.

Figure 2

Forest plots of adjusted risk ratios of body mass index for invasive ventilation stratified by ethnicity (n=4051). Models were adjusted for ethnicity, age, gender, income, smoking history, pregnancy, hypertension, heart failure, diabetes, coronary artery disease, atherosclerosis, sleep apnoea, chronic obstructive pulmonary disease, chronic kidney disease, end-stage renal disease, HIV, cerebrovascular disease, chronic liver disease, fatty liver, immunosuppressive treatment and malignancy. BMI, body mass index.

Figure 3

Forest plots of adjusted risk ratios of body mass index for mortality stratified by ethnicity (n=5670). Models were adjusted for ethnicity, age, gender, income, smoking history, pregnancy, hypertension, heart failure, diabetes, coronary artery disease, atherosclerosis, sleep apnoea, chronic obstructive pulmonary disease, chronic kidney disease, end-stage renal disease, HIV, cerebrovascular disease, chronic liver disease, fatty liver, immunosuppressive treatment and malignancy. BMI, body mass index.