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. 2023 May 24;5(5):CD015201.
doi: 10.1002/14651858.CD015201.

Obesity as an independent risk factor for COVID-19 severity and mortality

Borna Tadayon Najafabadi #  1 , Daniel G Rayner #  2 , Kamyar Shokraee  3 , Kamran Shokraie  4 , Parsa Panahi  5 , Paravaneh Rastgou  6 , Farnoosh Seirafianpour  7 , Feryal Momeni Landi  8 , Pariya Alinia  4 , Neda Parnianfard  9 , Nima Hemmati  3 , Behrooz Banivaheb  3 , Ramin Radmanesh  10   11 , Saba Alvand  12 , Parmida Shahbazi  13 , Hojat Dehghanbanadaki  14 , Elaheh Shaker  15 , Kaveh Same  4 , Esmaeil Mohammadi  15 , Abdullah Malik  16 , Ananya Srivastava  16 , Peyman Nejat  4 , Alice Tamara  17   18 , Yuan Chi  19   20 , Yuhong Yuan  21 , Nima Hajizadeh  13 , Cynthia Chan  22 , Jamie Zhen  22 , Dicky Tahapary  17   23 , Laura Anderson  24 , Emma Apatu  24 , Anel Schoonees  25 , Celeste E Naude  25 , Lehana Thabane  1 , Farid Foroutan  1
Affiliations

Obesity as an independent risk factor for COVID-19 severity and mortality

Borna Tadayon Najafabadi et al. Cochrane Database Syst Rev. .

Abstract

Background: Since December 2019, the world has struggled with the COVID-19 pandemic. Even after the introduction of various vaccines, this disease still takes a considerable toll. In order to improve the optimal allocation of resources and communication of prognosis, healthcare providers and patients need an accurate understanding of factors (such as obesity) that are associated with a higher risk of adverse outcomes from the COVID-19 infection.

Objectives: To evaluate obesity as an independent prognostic factor for COVID-19 severity and mortality among adult patients in whom infection with the COVID-19 virus is confirmed.

Search methods: MEDLINE, Embase, two COVID-19 reference collections, and four Chinese biomedical databases were searched up to April 2021.

Selection criteria: We included case-control, case-series, prospective and retrospective cohort studies, and secondary analyses of randomised controlled trials if they evaluated associations between obesity and COVID-19 adverse outcomes including mortality, mechanical ventilation, intensive care unit (ICU) admission, hospitalisation, severe COVID, and COVID pneumonia. Given our interest in ascertaining the independent association between obesity and these outcomes, we selected studies that adjusted for at least one factor other than obesity. Studies were evaluated for inclusion by two independent reviewers working in duplicate. DATA COLLECTION AND ANALYSIS: Using standardised data extraction forms, we extracted relevant information from the included studies. When appropriate, we pooled the estimates of association across studies with the use of random-effects meta-analyses. The Quality in Prognostic Studies (QUIPS) tool provided the platform for assessing the risk of bias across each included study. In our main comparison, we conducted meta-analyses for each obesity class separately. We also meta-analysed unclassified obesity and obesity as a continuous variable (5 kg/m2 increase in BMI (body mass index)). We used the GRADE framework to rate our certainty in the importance of the association observed between obesity and each outcome. As obesity is closely associated with other comorbidities, we decided to prespecify the minimum adjustment set of variables including age, sex, diabetes, hypertension, and cardiovascular disease for subgroup analysis. MAIN RESULTS: We identified 171 studies, 149 of which were included in meta-analyses. As compared to 'normal' BMI (18.5 to 24.9 kg/m2) or patients without obesity, those with obesity classes I (BMI 30 to 35 kg/m2), and II (BMI 35 to 40 kg/m2) were not at increased odds for mortality (Class I: odds ratio [OR] 1.04, 95% confidence interval [CI] 0.94 to 1.16, high certainty (15 studies, 335,209 participants); Class II: OR 1.16, 95% CI 0.99 to 1.36, high certainty (11 studies, 317,925 participants)). However, those with class III obesity (BMI 40 kg/m2 and above) may be at increased odds for mortality (Class III: OR 1.67, 95% CI 1.39 to 2.00, low certainty, (19 studies, 354,967 participants)) compared to normal BMI or patients without obesity. For mechanical ventilation, we observed increasing odds with higher classes of obesity in comparison to normal BMI or patients without obesity (class I: OR 1.38, 95% CI 1.20 to 1.59, 10 studies, 187,895 participants, moderate certainty; class II: OR 1.67, 95% CI 1.42 to 1.96, 6 studies, 171,149 participants, high certainty; class III: OR 2.17, 95% CI 1.59 to 2.97, 12 studies, 174,520 participants, high certainty). However, we did not observe a dose-response relationship across increasing obesity classifications for ICU admission and hospitalisation.

Authors' conclusions: Our findings suggest that obesity is an important independent prognostic factor in the setting of COVID-19. Consideration of obesity may inform the optimal management and allocation of limited resources in the care of COVID-19 patients.

PubMed Disclaimer

Conflict of interest statement

AS: partially supported by the Research, Evidence and Development Initiative (READ‐It). READ‐It (project number 300342‐104) is funded by UK aid from the UK government; however, the views expressed do not necessarily reflect the UK government's official policies.

CEN: partially supported by the Research, Evidence and Development Initiative (READ‐It). READ‐It (project number 300342‐104) is funded by UK aid from the UK government; however, the views expressed do not necessarily reflect the UK government's official policies; partial support paid to my institution by WHO for a scoping review on total fat intake and health outcomes other than measures of unhealthy weight gain, a systematic review on low sodium salt substitutes and cardiovascular health, rapid scoping reviews on coconut and palm oil intake and cardiovascular health, and a scoping review on the health effects of tropical oil consumption; co‐director of Cochrane Nutrition but did not have any involvement in the editorial process for this review.

LNA is supported by a research grant from the Canadian Institutes of Health Research.

FF is an editor with the Cochrane Prognosis Methods Group, but did not participate in the editorial process for this review.

All other authors have no interests to declare.

Figures

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Study flow diagram
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References

References to studies included in this review

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Halasz 2020 {published data only}
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Hashemi 2020 {published data only}
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Hendra 2021 {published data only}
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Hendren 2021 {published data only}
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Hernandez‐Galdamez 2020 {published data only}
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Hosseinzadeh 2021 {published data only}
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Hu 2020 {published data only}
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Huang 2020 {published data only}
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Huh 2020 {published data only}
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Hur 2020 {published data only}
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Iaccarino 2020 {published data only}
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Imam 2020 {published data only}
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Ioannou 2020 {published data only}
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Jayanama 2021 {published data only}
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Jirapinyo 2020 {published data only}
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Kaeuffer 2020 {published data only}
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Kalligeros 2020 {published data only}
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Kammar‐García 2020 {published data only}
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Khawaja 2020 {published data only}
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Killerby 2020 {published data only}
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Kim 2020a {published data only}
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Kim 2020b {published data only}
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Kim 2020c {published data only}
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Klang 2020 {published data only}
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Klineova 2020 {published data only}
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Kompaniyets 2021 {published data only}
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Krieger 2021 {published data only}
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Kuderer 2020 {published data only}
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Li 2020 {published data only}
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Li 2021 {published data only}
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Lohia 2021 {published data only}
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Louapre 2020 {published data only}
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Manohar 2021 {published data only}
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McNeill 2021 {published data only}
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Mehta 2021a {published data only}
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Mehta 2021b {unpublished data only}
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Merzon 2022 {published data only}
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Monteiro 2020 {published data only}
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Mostaghim 2020 {published data only}
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Motaib 2021 {published data only}
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Muñoz‐Rodríguez 2021 {published data only}
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Nachega 2020 {published data only}
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Nakeshbandi 2020 {published data only}
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Neveu 2021 {published data only}
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Newton 2020 {unpublished data only}
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Nicholson 2021 {published data only}
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Nyabera 2020 {published data only}
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Olivas‐Martínez 2021 {published data only}
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Omrani 2020 {published data only}
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Pablos 2020 {published data only}
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Palaiodimos 2020 {published data only}
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Parikh 2020 {published data only}
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Parra‐Bracamonte 2020 {published data only}
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Pattou Lille 2020 {published data only}
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Pena 2021 {published data only}
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Pepe 2021 {published data only}
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Petersen 2020 {unpublished data only}
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Petrilli 2020 {published data only}
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Pettit 2020 {published data only}
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Pongpirul 2020 {published data only}
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Price‐Haywood 2020 {published data only}
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Quan 2021 {published data only}
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Rapp 2020 {published data only}
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Recalde 2020 {unpublished data only}
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Rechtman 2020 {published data only}
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Rodriguez‐Gonzalez 2021 {published data only}
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Rojas‐Marte 2021 {published data only}
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Roomi 2020 {published data only}
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Rossi 2020 {published data only}
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Rottoli 2020 {published data only}
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Rubio‐Rivas 2020 {published data only}
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Sacco 2020 {published data only}
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Salari 2020 {published data only}
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Satman 2021 {published data only}
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Schavemaker 2021 {published data only}
    1. Schavemaker R, Schultz MJ, Lagrand WK, Van Slobbe-Bijlsma ER, Neto AS, Paulus F, et al. Associations of body mass index with ventilation management and clinical outcomes in invasively ventilated patients with ARDS related to COVID-19: insights from the PRoVENT-COVID study. Journal of Clinical Medicine 2021;10(6):1176. [DOI: 10.3390/jcm10061176] - DOI - PMC - PubMed
Shah 2020 {published data only}
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Sidhu 2020 {published data only}
    1. Sidhu F, Nedunchezhian S, Padilla-Carrasquillo L, Sabharwal N, Khalafi S, Ayoub A, et al. Body mass index and fatal outcome in patients hospitalized for Covid 19. Circulation 2020;142:A15852. [DOI: 10.1161/circ.142.suppl_3.15852] - DOI
Simonnet 2020 {published data only}
    1. Simonnet A, Chetboun M, Poissy J, Raverdy V, Noulette J, Duhamel A, et al. High prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) requiring invasive mechanical ventilation. Obesity 2020;28(7):1195-9. [DOI: 10.1002/oby.22831] - DOI - PMC - PubMed
Smati 2021a {published data only}
    1. Smati S, Tramunt B, Wargny M, Caussy C, Gaborit B, Vatier C, et al. Relationship between obesity and severe COVID-19 outcomes in patients with type 2 diabetes: results from the CORONADO study. Diabetes, Obesity and Metabolism 2021;23(2):391-403. [DOI: 10.1111/dom.14228] - DOI - PMC - PubMed
Smati 2021b {published data only}
    1. Smati H, Cohen PA, Nagda DV, Saravanan Y, Kalugin PN, Li CY, et al. Risk factors for hospitalization among patients with COVID-19 at a community ambulatory clinic in Massachusetts during the initial pandemic surge. Journal of Immigrant and Minority Health 2021;23(5):1110-5. [DOI: 10.1007/s10903-021-01189-5] - DOI - PMC - PubMed
Soares 2020 {published data only}
    1. Soares RCM, Mattos LR, Raposo LM. Risk factors for hospitalization and mortality due to COVID-19 in Espírito Santo state, Brazil. American Journal of Tropical Medicine and Hygiene 2020;103(3):1184-90. [DOI: 10.4269/ajtmh.20-0483] - DOI - PMC - PubMed
Sonmez 2021 {published data only}
    1. Sonmez A, Demirci I, Haymana C, Tasci I, Dagdelen S, Salman S, et al. Clinical characteristics and outcomes of COVID-19 in patients with type 2 diabetes in Turkey: a nationwide study (TurCoviDia). Journal of Diabetes 2021;13(7):585-95. [DOI: 10.1111/1753-0407.13171] - DOI - PMC - PubMed
Sterling 2020 {published data only}
    1. Sterling RK, Oakes T, Gal TS, Stevens MP, DeWit M, Sanyal AJ. The fibrosis-4 index is associated with need for mechanical ventilation and 30-day mortality in patients admitted with coronavirus disease 2019. Journal of Infectious Diseases 2020;222(11):1794-7. [DOI: 10.1093/infdis/jiaa550] - DOI - PMC - PubMed
Suleyman 2020 {published data only}
    1. Suleyman G, Fadel RA, Malette KM, Hammond C, Abdulla H, Entz A, et al. Clinical characteristics and morbidity associated with coronavirus disease 2019 in a series of patients in metropolitan Detroit. JAMA Network Open 2020;3(6):e2012270. [DOI: 10.1001/jamanetworkopen.2020.12270] - DOI - PMC - PubMed
Suresh 2021 {published data only}
    1. Suresh S, Siddiqui M, Ghanimeh MA, Jou J, Simmer S, Mendiratta V, et al. Association of obesity with illness severity in hospitalized patients with COVID-19: a retrospective cohort study. Obesity Research & Clinical Practice 2021;15(2):172-176. [DOI: 10.1016/j.orcp.2021.02.006] - DOI - PMC - PubMed
Tartof 2020 {published data only}
    1. Tartof SY, Qian L, Hong V, Wei R, Nadjafi RF, Fischer H, et al. Obesity and mortality among patients diagnosed with COVID-19: results from an integrated health care organization. Annals of Internal Medicine 2020;173(10):773-81. [DOI: 10.7326/M20-3742] - DOI - PMC - PubMed
Tchang 2021 {published data only}
    1. Tchang BG, Askin G, Sahagun A, Hwang J, Huang H, Curanaj FAM, et al. The independent risk of obesity and diabetes and their interaction in COVID-19: a retrospective cohort study. Obesity 2021;29(6):971-5. [DOI: 10.1002/oby.23172] - DOI - PMC - PubMed
Thomson 2020 {published data only}
    1. Thomson RJ, Hunter J, Dutton J, Schneider J, Khosravi M, Casement A, et al. Clinical characteristics and outcomes of critically ill patients with COVID-19 admitted to an intensive care unit in London: a prospective observational cohort study. PLOS One 2020;15(12):e0243710. [DOI: 10.1371/journal.pone.0243710] - DOI - PMC - PubMed
Toussie 2020 {published data only}
    1. Toussie D, Voutsinas N, Finkelstein M, Cedillo MA, Manna S, Maron SZ, et al. Clinical and chest radiography features determine patient outcomes in young and middle-aged adults with COVID-19. Radiology 2020;297(1):E197-206. [DOI: 10.1148/radiol.2020201754] - DOI - PMC - PubMed
Tsai 2021 {published data only}
    1. Tsai S, Nguyen H, Ebrahimi R, Barbosa MR, Ramanan B, Heitjan DF, et al. COVID-19 associated mortality and cardiovascular disease outcomes among US women veterans. Scientific Reports 2021;11(1):8497. [DOI: 10.1038/s41598-021-88111-z] - DOI - PMC - PubMed
Van Zelst 2020 {published data only}
    1. Van Zelst CM, Janssen ML, Pouw N, Birnie E, Cabezas MC, Braunstahl GJ. Analyses of abdominal adiposity and metabolic syndrome as risk factors for respiratory distress in COVID-19. BMJ Open Respiratory Research 2020;7(1):e000792. [DOI: 10.1136/bmjresp-2020-000792] - DOI - PMC - PubMed
Vousden 2021 {unpublished data only}
    1. Vousden N, Bunch K, Morris E, Simpson N, Gale C, O’Brien P, et al. The incidence, characteristics and outcomes of pregnant women hospitalized with symptomatic and asymptomatic SARS-CoV-2 infection in the UK from March to September 2020: a national cohort study using the UK Obstetric Surveillance System (UKOSS). medRxiv 2021. [DOI: 10.1101/2021.01.04.21249195] - DOI - PMC - PubMed
Wang 2020a {published data only}
    1. Wang Z, Zheutlin A, Kao YH, Ayers K, Gross S, Kovatch P, et al. Hospitalised COVID-19 patients of the Mount Sinai Health System: a retrospective observational study using the electronic medical records. BMJ Open 2020;10(10):e040441. [DOI: 10.1136/bmjopen-2020-040441] - DOI - PMC - PubMed
Wang 2020b {published data only}
    1. Wang J, Zhu L, Liu L, Zhao X, Zhang Z, Xue L, et al. Overweight and obesity are risk factors of severe illness in patients with COVID-19. Obesity 2020;28(11):2049-55. [DOI: 10.1002/oby.22979] - DOI - PMC - PubMed
Wang 2021a {published data only}
    1. Wang M, Yang F, Zhu X, Cheng C, Li Q, Zhao T, et al. Clinical characteristics and outcome of novel coronavirus pneumonia patients with different body mass index. Chinese Journal of Endocrinology and Metabolism 2021;12:17-22.
Wang 2021b {published data only}
    1. Wang Y, Yao S, Liu X, Cao Y, Wang Y, Xie M. Risk factors of coronavirus disease 2019-related mortality and optimal treatment regimens: a retrospective study. Medical Science Monitor 2021;29:e926751. [DOI: 10.12659/MSM.926751] - DOI - PMC - PubMed
Wu 2021 {published data only}
    1. Wu X, Li C, Chen S, Zhang S, Wang F, Shi T, et al. Association of body mass index with severity and mortality of COVID-19 pneumonia: a two-center, retrospective cohort study from Wuhan, China. Aging 2021;13(6):7767-80. [DOI: 10.18632/aging.202813] - DOI - PMC - PubMed
Xie 2021 {published data only}
    1. Xie J, Zu Y, Alkhatib A, Pham TT, Gill F, Jang A, et al. Metabolic syndrome and COVID-19 mortality among adult black patients in New Orleans. Diabetes Care 2020;44(1):188-93. [DOI: 10.2337/dc20-1714] - DOI - PMC - PubMed
Xu 2020 {published data only}
    1. Xu J, Zhao F, Han M, Ma L, Zhang T. Analysis of the clinical characteristics and early warning model construction of severe/critical coronavirus disease 2019 patients. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue 2020;32(4):401-6. [DOI: 10.3760/cma.j.cn121430-20200325-00410] - DOI - PubMed
Yates 2021a {published data only}
    1. Yates T, Razieh C, Zaccardi F, Rowlands AV, Seidu S, Davies MJ, et al. Obesity, walking pace and risk of severe COVID-19 and mortality: analysis of UK Biobank. International Journal of Obesity 2021;45(5):1155-9. [DOI: 10.1038/s41366-021-00771-z] - DOI - PMC - PubMed
Yates 2021b {published data only}
    1. Yates T, Zaccardi F, Islam N, Razieh C, Gillies CL, Lawson CA, et al. Obesity, ethnicity, and risk of critical care, mechanical ventilation, and mortality in patients admitted to hospital with COVID-19: analysis of the ISARIC CCP-UK cohort. Obesity 2021;29(7):1223-30. [DOI: 10.1002/oby.23178] - DOI - PMC - PubMed
Yazdanpanah 2021 {published data only}
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Yi 2020 {published data only}
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Yoshida 2021 {published data only}
    1. Yoshida Y, Gillet SA, Brown MI, Zu Y, Wilson SM, Ahmed SJ, et al. Clinical characteristics and outcomes in women and men hospitalized for coronavirus disease 2019 in New Orleans. Biology of Sex Differences 2021;12(1):20. [DOI: 10.1186/s13293-021-00359-2] - DOI - PMC - PubMed
Yu 2020a {published data only}
    1. Hongwei Y, Shizhen X, Zaoxian M. An analysis of clinical features and influencing factors of patients with new coronavirus pneumoina. Jiangsu Medical Journal 2020;46(9):904-7.
Yu 2020b {published data only}
    1. Yu T, Cai S, Zheng Z, Cai X, Liu Y, Yin S, et al. Association between clinical manifestations and prognosis in patients with COVID-19. Clinical Therapeutics 2020;42(6):964-72. [DOI: 10.1016/j.clinthera.2020.04.009] - DOI - PMC - PubMed
Zaferani Arani 2021 {published data only}
    1. Zaferani Arani H, Manshadi GD, Atashi HA, Nejad AR, Ghorani SM, Abolghasemi S, et al. Understanding the clinical and demographic characteristics of second coronavirus spike in 192 patients in Tehran, Iran: a retrospective study. PLOS One 2021;16(3):e0246314. [DOI: 10.1371/journal.pone.0246314] - DOI - PMC - PubMed
Zamoner 2021 {published data only}
    1. Zamoner W, Santos CAS, Magalhães LE, Oliveira PGS, Balbi AL, Ponce D. Acute kidney injury in COVID-19: 90 days of the pandemic in a Brazilian public hospital. Frontiers in Medicine 2021;8:622577. [DOI: 10.3389/fmed.2021.622577] - DOI - PMC - PubMed
Zhang 2021 {published data only}
    1. Zhang J, Xu Y, Shen B, He H, Liu M, Zhao M, et al. The association between obesity and severity in patients with coronavirus disease 2019: a retrospective, single-center study, Wuhan. International Journal of Medical Sciences 2021;18(8):1768-77. [DOI: 10.7150/ijms.54655] - DOI - PMC - PubMed
Zhu 2020 {published data only}
    1. Zhu Z, Hasegawa K, Ma B, Fujiogi M, Camargo CA, Liang L. Association of obesity and its genetic predisposition with the risk of severe COVID-19: analysis of population-based cohort data. Metabolism 2020;112:154345. [DOI: 10.1016/j.metabol.2020.154345] - DOI - PMC - PubMed

References to studies excluded from this review

Bhasin 2020 {published data only}
    1. Bhasin A, Nam H, Yeh C, Lee J, Liebovitz D, Achenbach C. Is BMI higher in younger patients with COVID-19? Association between BMI and COVID-19 hospitalization by age. Obesity 2020;28(10):1811-4. [DOI: 10.1002/oby.22947] - DOI - PMC - PubMed
Cummings 2020 {published data only}
    1. Cummings MJ, Baldwin MR, Abrams D, Jacobson SD, Meyer BJ, Balough EM, et al. Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study. Lancet 2020;395(10239):1763-70. [DOI: 10.1016/S0140-6736(20)31189-2] - DOI - PMC - PubMed
Hernández‐Garduño 2020 {published data only}
    1. Hernández-Garduño E. Obesity is the comorbidity more strongly associated for Covid-19 in Mexico. A case-control study. Obesity Research & Clinical Practice 2020;14(4):375–9. [DOI: 10.1016/j.orcp.2020.06.001] - DOI - PMC - PubMed
Lighter 2020 {published data only}
    1. Lighter J, Phillips M, Hochman S, Sterling S, Johnson D, Francois F, et al. Obesity in patients younger than 60 years is a risk factor for COVID-19 hospital admission. Clinical Infectious Diseases 2020;71(15):896-7. [DOI: 10.1093/cid/ciaa415] - DOI - PMC - PubMed
Steinberg 2020 {published data only}
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Williamson 2020 {published data only}
    1. Williamson EJ, Walker AJ, Bhaskaran K, Bacon S, Bates C, Morton CE, et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature 2020 ;584:430-6. [DOI: 10.1038/s41586-020-2521-4] - DOI - PMC - PubMed
Yates 2020 {published data only}
    1. Yates T, Razieh C, Zaccardi F, Davies MJ, Khunti K. Obesity and risk of COVID-19: analysis of UK biobank. Primary Care Diabetes 2020;14(5):566–7. [DOI: 10.1016/j.pcd.2020.05.011] - DOI - PMC - PubMed
Zhang 2020 {published data only}
    1. Zhang F, Xiong Y, Wei Y, Hu Y, Wang F, Li G, et al. Obesity predisposes to the risk of higher mortality in young COVID-19 patients. Journal of Medical Virology 2020;92(11):2536-42. [DOI: 10.1002/jmv.26039] - DOI - PMC - PubMed

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