Obesity, diabetes and COVID-19: What PCPs need to know
The CDC lists people with severe obesity, defined as a BMI of at least 40 kg/m2, and diabetes as being at high risk for developing severe illness from COVID-19.
A case study in China showed that from the beginning of the outbreak through Feb. 11, 2020, the death rate among patients with COVID-19 who had diabetes was 7.3% compared with 0.9% in those without comorbid conditions.
Harold Bays, MD, chief science officer of the obesity medical association and the medical director and president of Louisville Metabolic and Atherosclerosis Research Center Inc., told Healio Primary Care that patients with obesity and diabetes often have worsened immune function, putting them at increased risk for developing COVID-19 infection and poor outcomes once infected. Therefore, primary care providers should empower patients with practical information on infection prevention and safe practices during the COVID-19 pandemic.
William S. Yancy Jr., MD, MHS, FTOS, director of the Duke University Diet and Fitness Center, told Healio Primary Care that patients with diabetes and obesity should take typical steps to prevent COVID-19 infection — like frequent hand washing and practicing social distancing — in addition to getting enough sleep, physical activity and maintaining a healthy diet to help control their conditions and improve immunity.
“Preventing COVID is even more important in people with obesity or diabetes, however, because the risk of severe disease is higher,” he said.
Worsened immunity, comorbid conditions
Bays explained that patients with obesity and diabetes have compromised innate and acquired immunity, which creates a “double whammy.”
Yancy noted that those with diabetes have an increased risk for infection “because elevated blood sugar increases risk by causing dysfunction of the immune system — conversely, better control of blood sugar can decrease risk in patients known to have diabetes.”
“Losing weight, lowering blood pressure and controlling blood sugar have always been important for preventing severe health consequences, but the risk of severe COVID infection is now another reason to focus on these issues,” he continued.
In addition to lowered immunity, Bays explained that people with obesity often have sleep apnea and other lung abnormalities that can result in hypoxia even before any infection occurs. This leaves little room for any further injury to the lungs, as might occur with COVID-19.
“Anything that further compromises the lungs can be devastating to a patient with obesity,” Bays said.
As patients with obesity are at an increased risk for developing numerous health conditions — including type 2 diabetes, hypertension, certain types of cancers, stroke and coronary heart disease — Bays explained that many patients require multiple medications for these conditions, which means they may be “less able to afford the medications to treat anything other than what they already have.”
Yancy noted that among those with obesity and diabetes who develop COVID-19, physicians and patients alike “should be more vigilant in watching for symptoms or signs of worsening infection.”
“Increasing difficulty with breathing, high fever, chest pain or low oxygen levels can signal worsening COVID disease,” he continued. “Oxygen levels can be monitored by a pulse oximeter on the finger or noted to be low if a patient’s fingers or lips appear blue in color.”
Stress worsening those infected, affected
Stress can also play a major role in worsening outcomes among patients with diabetes and obesity even if they do not become infected, according to Bays.
“If stress impairs the immune system, then this may increase the risk of infection, or worsen outcomes to the infection,” he said.
Aside from being infected, Bays explained that a common clinical challenge is how the stress of the COVID-19 pandemic adversely affects patients with obesity. He noted that this stress combined with recommendations to stay home increase the risk for worsened nutrition and decreased physical activity. As a result, Bays said that for many patients, “weight is going to get worse, their blood sugar is going to get worse and blood pressure is going to get worse.”
Some patients may be scared to go outside, Bays said. They may also be turning to unhealthful comfort foods while staying at home without realizing this could worsen their condition.
“We should not underestimate the implications of mental stress in creating physical problems,” Bays said. “A discussion of the adverse effects of stress upon patient health, and how to manage it, could be among the most productive things primary care clinicians could focus upon during their telemedicine encounters.”
PCPs can provide critical guidance to help educate their patients during the COVID-19 epidemic. Physicians can tell patients to prioritize healthful foods in their home and maintain some physician activity while social distancing and taking other preventive measures, according to Bays.
In addition to offering interventions that would typically be recommended for reducing stress, Bays said that physicians should inform patients about positive updates on the COVID-19 pandemic.
He explained that informing patients about COVID-19 “just can’t be the minute-to-minute, hour-to-hour, day-to-day pounding upon people who are already stressed to the max and only telling them how horrible things are now, and for the foreseeable future.”
Although physicians may be concerned that being optimistic could cause patients to ease up on social distancing and other measures to prevent infection, Bays stressed that as long as patients are accurately informed about the virus, they will continue to take preventive measures seriously, even if they receive “hopeful news.”
“I think it’s OK to give somebody a prescription of hope,” Bays said. “In these times, I think hope might be one of the best things you can offer your patients.” – by Erin Michael
CCDC. Vital Surveillances: The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020. http://weekly.chinacdc.cn/en/article/id/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51?fbclid=IwAR0t2qQ3Gjq6tMv1uPQ_IW7dWmtgR3YhXXQKHYz1P77KnbDF665hSCmJfYo. Accessed March 27, 2020.
CDC. People who are at higher risk for severe illness. https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/people-at-higher-risk.html. Accessed March 26, 2020.
CDC. The Health Effects of Overweight and Obesity. https://www.cdc.gov/healthyweight/effects/index.html. Accessed March 27, 2020.
Disclosures: Bays reports no relevant financial disclosures.Yancy reports being an occasional consultant for dietdoctor.com and previously consulting for Guideline Central.