Long COVID-19 among patients with obesity ‘may be missed or misdiagnosed’
Since the start of the COVID-19 pandemic, research has shown that patients with obesity have increased risks for adverse events, including symptomatic disease, hospitalization, ICU admission and other poor outcomes.
A recent study found that patients with obesity are also at an increased risk for developing long COVID-19.
Healio spoke with study author Bartolome Burguera, MD, Chair of the Endocrinology and Metabolism Institute and a professor in the Lerner Institute of Medicine at the Cleveland Clinic, and Kristin Englund, MD, an infectious disease physician who leads the reCOVer Clinic — the Cleveland Clinic’s center for patients with long COVID-19 —to learn more about long COVID-19 among patients with obesity.
Healio: How common is long COVID-19 in patients with obesity?
Burguera: Based on the research we published in Diabetes, Obesity, and Metabolism, “Among COVID-19 survivors, risk of hospital admission after the acute phase of the disease was 30% higher in patients with obesity.”
Specifically, during a 10-month follow-up after the acute phase of COVID-19, 44% of the study participants had required hospital admission and 1% died. Further, results show that compared with patients with normal BMI, the risk for 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. More specifically, the need for diagnostic tests to assess cardiac, pulmonary, vascular, renal, gastrointestinal and mental health problems was significantly higher in patients with a BMI of 35 or greater, compared with normal BMI patients.
Healio: What long COVID-19 symptoms are most common among patients with obesity? How long could these symptoms last?
Burguera: The following information is based on our research findings: We found that “in a median follow-up time of 8 months and counting from 30days following a positive viral test, 1,230 (43%) patients required diagnostic tests, 1,255 (44%) patients underwent hospital admission, and 29 (1%) patients died. Assessments of pulmonary (23%) and cardiac (22%) problems were the most common investigations in the follow-up of COVID-19 survivors (Table 1).”The study included 2,839 patients (52% women; 58% white; mean age, 52.7 ± 20.1years) who did not require ICU admission and survived the acute phase of COVID-19.
Healio: What might be the cause of the elevated risk for long COVID-19 among patients with obesity?
Burguera: Obesity, as a pro-inflammatory 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.
The observations of this study can possibly be explained by the underlying mechanisms at work in patients who have obesity, such as hyper-inflammation, immune dysfunction, and comorbidities. Those conditions can lead to poor outcomes in the acute phase of COVID-19 in patients with obesity and could possibly lead to an increased risk for long-term complications of COVID-19 in this patient population.
Healio: What treatment options are available for long COVID-19?
Englund: Patients who present with a post-COVID 19 disorder come in with a wide variety of symptom-related complaints. There is not one specific treatment. The treatment has to be specifically directed for each patient.
When we evaluate patients, we look at all different organ systems because this virus can affect any part of the body. Some patients may present with headache and fatigue. Others may present with shortness of breath and chest pain. So, the treatments can differ greatly.
We evaluate different parts of the body whether through a physical exam and/or patients entering data on a questionnaire looking at overall complaints of fatigue, sleep issues, and mental health issues. We do several different evaluations looking at their heart, lungs, and do blood tests.
Based upon the evaluation results and symptom-related complaints from patients, we refer patients to different specialists. In fact, in our reCOVer clinic, we have been referring patients to 18 different specialists.
Healio: What barriers to care do patients with obesity face when seeking treatment for long COVID-19?
Englund: Some of that may be due to some of the symptoms of post-COVID 19 associated with obesity instead of the SARS-CoV-2 infection. For instance, for a patient with obesity who had COVID-19 and is feeling fatigued, that symptom would be attributed to obesity instead of being identified as a long-term complication of COVID-19. So, some of the post-COVID-19 symptoms may be missed or misdiagnosed.
Some patients may not feel comfortable bringing up their symptoms for fear of being seen as someone who complains or feeling of being judged.
Some patients may not know what symptoms to be looking for as the virus is still relatively new. New symptoms can appear 3 to 6 months after the initial infection and may not be connected to the prior SARS-CoV-2 infection.
The prospect of traveling to an exam and coming in for further testing may be a difficult prospect for patients who have a very high BMI. Some of the evaluations involve certain studies — e.g., pulmonary function test, echocardiogram — that may be challenging for people who have a high BMI. For instance, if a patient with a very high BMI was referred to a pulmonologist who needs a CAT scan to further evaluate the patient, the doctor’s office may need special equipment to evaluate this patient population due to the weight limits of certain machines.
Healio: How could long COVID-19 impact the long-term health of patients with obesity?
Englund: For most patients in our clinic, fatigue is one of the most common symptoms. As part of a comprehensive approach to weight management, maintaining a certain level of exercise is recommended. For patients with obesity who are experiencing fatigue from long COVID-19, it may add to the challenge of maintaining a certain level of activity, which may lead to additional weight gain.
Healio: What research is underway to evaluate long COVID-19 among patients with obesity?
Burguera: Future studies are planned to confirm findings of this study that obesity is a major risk factor for the development of post-acute sequelae of COVID-19 (PASC) and determine the long-term and rigorous follow-up that patients with obesity need after a SARS-CoV-2 infection.
Englund: This current study helps us to understand and be able to predict who might be most at risk for developing long-term complications of COVID-19. If we know what puts someone at risk for developing PASC, it can help us to potentially understand ways to prevent it.
As we learn more about who is most at risk for PASC, we can hopefully start to decrease the number of people who develop PASC by focusing on prevention. The need for some hospitalization and diagnostic tests after the acute phase of the infection adds costs to health systems across the world. More research is needed to find ways to keep people from developing PASC.