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Roundtable Discussion: COVID-19 and Obesity—Implications and Integrative Management

2021; Mary Ann Liebert, Inc.; Volume: 27; Issue: 2 Linguagem: Inglês

10.1089/act.2021.29318.dlk

1557-9085

Jane Hart, David L. Katz, Robert F. Kushner, Beth Frates, Donald D. Hensrud,

Complementary and Alternative Medicine Studies

Alternative and Complementary TherapiesVol. 27, No. 2 Free AccessRoundtable Discussion: COVID-19 and Obesity—Implications and Integrative ManagementModerator: Jane Hart, Participants: David L. Katz, Robert F. Kushner, Beth Frates, and Donald D. HensrudModerator: Jane HartSearch for more papers by this author, Participants: David L. KatzDavid L. Katz, MD, MPH, FACPM, FACP, FACLM, is the founding director (1998–2019) of the Prevention Research Center at Yale University/Griffin Hospital, Derby, Connecticut, USA, the president of True Health Initiative, Tulsa, Oklahoma, USA, and the CEO of Diet ID, Detroit, Michigan, USA.Search for more papers by this author, Robert F. KushnerRobert F. Kushner, MD, MS, is a professor in the departments of medicine and medical education at Northwestern University Feinberg School of Medicine, and the director of the Center for Lifestyle Medicine at Northwestern Medicine, Chicago, Illinois, USA.Search for more papers by this author, Beth FratesBeth Frates, MD, FACLM, DipABLM, is a lifestyle medicine specialist and health and wellness coach at Wellness Synergy, LLC, and an assistant professor at Harvard Medical School, Boston, Massachusetts, USA.Search for more papers by this author, and Donald D. HensrudDonald D. Hensrud, MD, MPH, is an associate professor of preventive medicine and nutrition, division of general internal medicine, at Mayo Clinic College of Medicine, and medical director of the Mayo Clinic Healthy Living Program, Rochester, Minnesota, USA.Search for more papers by this authorPublished Online:12 Apr 2021https://doi.org/10.1089/act.2021.29318.dlkAboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail Dr. Hart: Research suggests significantly increased risks of both hospitalization and death if a person who is obese develops COVID-19. What is our current understanding about degrees of obesity and the risk of developing COVID-19? What seems to be the mechanisms behind the risk?David L. Katz, MD: Famously, the dose makes the poison—and while Paracelsus was speaking of toxins and literal poisons, the same thinking pertains to cardiometabolic liability. Of course degree of obesity matters, just as the damage done to blood vessels by hypertension varies with magnitude, the propagation of atherosclerosis by hyperlipidemia varies with its severity, and so on. Stage 2 obesity (i.e., body mass index [BMI] >35) and in particular stage 3 obesity (i.e., BMI >40) stand out as leading indicators of adverse COVID-19 outcomes in young people, notably those under age 40. Greater degrees of obesity mean not only more and larger adipocytes, but more influence on circulating hormones and cytokines that influence immune response. A principal mechanism by which obesity compounds COVID-19 is immune dysfunction and inflammatory responses that are both exaggerated and ineffectual.There is another purely mechanical means by which relatively severe obesity exacerbates COVID-19. Early in the pandemic, the importance of positioning to improve oxygenation was discerned. I witnessed this first hand during a brief stint as a frontline volunteer in New York City. I also observed firsthand how much more difficult such frequent repositioning was—for patient and medical staff alike—when the patient had severe obesity. In addition, severe obesity is a long-established risk factor for respiratory ailments in general because of potential constraints on normal lung excursions and tidal volume.I hasten to note that while we may "blame" obesity for some element of COVID-19 risk, we may NOT blame victims of obesity for suffering the condition. Obesity is a "social" disease if a disease at all, mediated by an obesogenic environment and culture, and much propagated by social disparities that are, in turn, independent risk factors for adverse COVID-19 outcomes.Robert F. Kushner, MD: Shortly after COVID-19 reached the United States it became apparent that obesity was a risk factor for severe illness, prompting the Centers for Disease Control and Prevention (CDC) to include obesity (BMI ≥30 kg/m2) on its list of at-risk underlying medical conditions. Over the past year, multiple studies from small single-site medical centers to large retrospective analyses of health care systems have consistently shown a significant association between BMI and increased risk for admission to the intensive care unit (ICU), need for invasive mechanical ventilation, and death. The increased risk is particularly noted among those with moderate to severe obesity, males and younger age (approximately 30 but 40 kg/m2).2 In addition, there is some evidence that even being in the overweight BMI category (BMI 25–30 kg/m2) increases the risk of COVID-19 by 44%.3One way to explore the association between obesity and COVID-19 is to examine the mechanistic changes in obesity and its physical changes.1 Mechanistic changes include metabolic dysfunction, immune impairment, and adipose inflammation as outlined in the article by Popkin et al. titled, "Individuals with obesity and COVID-19: A global perspective on the epidemiology and biological relationships."1 For metabolic dysfunction in obesity, there is an increase in insulin and leptin, a decrease in adiponectin, and an increase in hypoxia and lipotoxicity. With regard to immune impairment, there is an imbalance of T helper cells altering the ratio of Th2 and Th1, a decrease in Tregs' (regulatory T cells) ability to suppress and clear immune cell-mediated inflammation after infection, and a decrease in specialized pro-resolving mediators, which are specialized pro-resolving lipid mediators that work to resolve inflammation. Adipose inflammation involves the alteration of a number of cytokines, including an increase in interleukin-6, C-reactive protein (CRP), granulocyte-macrophage colony-stimulating factor, and tumor necrosis factor-α and interferon-δ. With obesity, there is an increase in Th1 cells, macrophages, and cytotoxic T lymphocytes.As mentioned, there are physical changes that accompany obesity and impact a person's ability to fight the infection with the coronavirus. Visceral adiposity is one such change. In addition, excessive tissue around the neck measured in collar size often accompanies obesity and is a risk factor for obstructive sleep apnea. People with abdominal obesity also have lower lung capacity and an increased risk of other respiratory problems that increase the risk of hypoventilation-associated pneumonia. There is an association with decreased physical activity and obesity, and less exercise leads to lower cardiorespiratory fitness levels, which translates to less efficient delivery of oxygen to tissues throughout the body. This may also be a factor in the increased risk and increased severity of illness with COVID-19 in patients with obesity. It is important to mention that many people who are obese feel stigmatized by society and health care providers. This may result in patients with obesity delaying health care visits.Dr. Hart: Are there other important associations linked specifically to obesity and COVID-19 risk such as comorbidities, age, or gender that contribute? Or are all people who are obese carrying the same risk?Dr. Katz: This is a very important question. Not all obesity is created equal—simply on the basis of severity. But there are other important distinctions, too. We have long referred to a division in anthropometrics between gynoid or "pear" and android or "apple" pattern obesity. The sex-based distinction is common, but of course not perfectly reliable. In general, though, premenopausal women are more prone to store excess body fat in the lower extremities while men and postmenopausal women are more apt to store extra fat around the middle. Genetic and ethnic distinctions are relevant here as well, so the tale is not limited to sex. Whatever the underlying predispositions, the accumulation of fat around the middle is much more strongly linked to visceral fat accumulation, insulin resistance, the stigmata of the "metabolic syndrome," and type 2 diabetes than is lower extremity fat. Ultimately, it is the type (distribution) as well as degree of obesity that determines the metabolic contribution to COVID-19, while degree alone may have more to do with the mechanical contribution.Dr. Kushner: Most of the databases used to explore the association between obesity and COVID-19 complications have access to only demographic variables that are routinely captured in an electronic medical record, such as height, weight, age, gender, and race/ethnicity. From these data, we have learned that individuals with moderate to severe obesity that are male, younger, and belong to minority groups have an increased risk for complications. Hypotheses are now emerging to explain these associations. As Dr. Katz stated, males are more likely to have an increased abdominal fat distribution (android phenotype), which is associated with increased visceral and ectopic fat, lipotoxicity (increased adipokines and cytokines), and impaired diaphragmatic excursion, leading to reduced functional residual capacity and hypoxia.The heightened risk among disadvantaged populations places a spotlight on social determinants of health as an underlying contributor of risk, particularly the role of food deserts, the built environment, financial insecurity, and limited access to health care. Clearly, defining obesity by a single anthropometric measurement (BMI) is insufficient since BMI alone does not directly measure body fat, or distinguish body fat distribution, assess fitness, or assess an individuals' health status.Dr. Frates: As I stated before, obesity and severe obesity are 2 of the 12 risk factors identified as risk factors for COVID-19 by the CDC; however, it is important to point out that 3 of the other risk factors are highly correlated with obesity, including type 2 diabetes, heart disease, and cancer. People with more than one risk factor for COVID-19 are at increased risk for infection and serious illness. For example, with diabetes, the body has a disrupted immune response with reduced cytokine production, impaired phagocytosis, and dysfunction of immune cells. As noted earlier, people with obesity have mechanistic and physical changes that put them at risk for infection and subsequent severe problems due to COVID-19.4 People with obesity and diabetes have chronic low-level inflammation. This state could aggravate the inflammatory response to coronavirus infection, putting patients at increased risk for the cytokine storm that leads to pneumonia, acute respiratory distress syndrome, and ultimately multiple organ failure, which can occur in severe COVID-19 cases.5People with heart disease and obesity are at increased risk for severe disease as well. A healthy heart allows for optimal oxygen and nutrient delivery to all cells in the body. When the heart is not functioning properly, the delivery system is compromised, which can lead to worse oxygenation and greater physiologic dysfunction with COVID-19. With a fever, the body responds with a rapid heart rate, which can put strain on a heart muscle often already riddled with disease. In addition, pneumonia lowers oxygen saturation, which puts increased stress on the heart.6People with cancer are also at increased risk for morbidity and mortality. Research has demonstrated that cancer patients have significantly lower platelet levels and higher D-dimer levels, C-reactive protein levels, and prothrombin time, which makes them vulnerable to severe sequelae with COVID-19.7 Combining cancer with the mechanistic dysfunction and physiologic changes that accompany obesity puts patients at increased risk with respect to coronavirus infection.As mentioned, with respect to gender, data reveal that more men are dying of COVID-19 than women. Reasons for this gender difference may be attributed to differences in biology such as carrying adipose tissue in the abdominal region, pre-existing conditions, and the reluctance to seek health care.8 In addition, there is research supporting the fact that women are more likely to believe that COVID-19 is a serious health problem, more likely to agree with restraining public policy measures, and also more likely to comply with the policies.8Socioeconomic status plays a role in COVID-19 risk and severity of illness.9 People who live in areas that are densely populated and in households with members sharing bedrooms and other tight spaces are more likely to contract and spread the virus. Jobs that do not lend themselves to working from home such as bus drivers, grocery store clerks, and warehouse workers put people at risk for the virus day to day. Access to health care is another factor that comes into play with this disparity. People living in poverty may experience multiple barriers to visiting the doctor or going to the hospital. All of this can contribute to risk and severity of COVID-19.There is evidence that people who are black, Hispanic, and Asian are at increased risk of COVID-19.10,11 The reasons for this disparity are multifactorial and need further research.Donald D. Hensrud, MD: The bottom line is that obesity increases the risk of type 2 diabetes mellitus, hypertension, pulmonary disease, and cardiovascular disease and other conditions, all of which independently increase the risk, severity, and mortality of COVID-19 through various mechanisms. Insulin resistance, a hallmark of type 2 diabetes and present in many cases of obesity, is a key factor in increasing the inflammatory response. Regarding age, severe obesity appears to be the most important risk factor for severe disease in younger people. In contrast, prior bariatric surgery for obesity appears to be associated with decreased risk.Dr. Hart: What are some of the most promising integrative medicine interventions that clinicians should be aware of for addressing obesity and COVID-19? What is the role of nutritional medicine?Dr. Katz: There is much in the realm of nutritional medicine to help mitigate the ills of COVID-19 in no small measure because overall dietary pattern is the leading determinant of chronic disease risk in the United States and much of the modern world. A balanced high-quality plant-predominant diet is vital to immune function in various ways, and is also vital to the prevention or amelioration of leading COVID-19 risk factors such as diabetes, hypertension, and cardiovascular disease. Isolated nutrients of special interest include vitamin D, zinc, antioxidant families (i.e., carotenoids, flavonoids) and omega-3 fatty acids. Probiotics are another potential mediator of balanced immune responses. I would recommend with the most confidence, supplements of vitamin D and zinc as a type of preventive medicine insurance—likely to help a bit, unlikely to harm—with a dedicated focus on optimizing overall diet quality.But when it comes to obesity per se, the list is quickly truncated. Obesity really is a matter of energy balance, and as we have all heard—weight can be lost even on a junk food diet if energy intake is restricted. Thus, an enlightened integrated approach to managing weight for the sake of attenuating COVID-19 risk would extend well beyond weight to overall considerations of diet quality and nutritional status, and the ways these reverberate through every aspect of metabolic health.Dr. Kushner: Lifestyle counseling is foundational to obesity care, particularly during the COVID-19 pandemic. In addition to emphasizing consumption of a nutritionally balanced calorie-controlled diet as Dr. Katz mentioned, and engaging in ample physical activity and reducing sedentary time, increased attention needs to be directed toward using adaptive coping skills. COVID-19 has brought an unprecedented increase of stress for most people due to loss of "normalcy" of our lives, financial insecurity, and social isolation. The impact of stress on physical and mental health has been defined by the terms allostasis, allostatic state, and allostatic load. Allostatic load reflects the cumulative effects of experiences of daily life and the resulting health damaging behaviors, including poor sleep, social isolation, lack of exercise, and unhealthy diet—all manifestations of living during the COVID-19 pandemic. Mind–body therapies, such as yoga, meditation, mindfulness, guided imagery, t'ai chi, and mindfulness-based stress reduction, can be particularly useful to recommend to patients.Dr. Frates: Unfortunately, but not surprisingly, there is evidence that people are gaining weight during the pandemic mostly related to a change in lifestyle that includes staying home, sitting more, moving less, eating more along with increased stress levels, decreased social connection, decreased sleeping time, and increased alcohol consumption. All of these factors are powerful lifestyle factors. The six pillars of lifestyle medicine outlined by the American College of Lifestyle Medicine (ACLM) include routine exercise, a healthy diet, stress resiliency, sleeping seven to eight hours a day, cultivating social connections, and eliminating or moderating alcohol consumption (www.lifestylemedicine.org/ACLM/Tools_and_Resources/Print_Resources.aspx).One promising intervention for obesity during this pandemic is the use of online lifestyle medicine group interventions to help patients lose weight. During these group interventions, patients meet weekly for 6–12 weeks and they review guidelines and research in the six pillars as well as strategies to achieve the guidelines for each pillar. The information is helpful to patients, and the social connection online created during the sessions motivates the patients to make progress. Since all of the lifestyle medicine pillars are important to address for anyone who is working to lose weight, a comprehensive group intervention can help people gain the knowledge they need in digestible bites. The pandemic has made attending these sessions easier because they are online, and there are no travel costs, parking fees, or hassles of traffic.Helping patients find physical activity that they enjoy doing at home and identify online opportunities for group classes is one way to empower people with obesity to make a healthy change during this pandemic. Encouraging patients to adopt a whole food predominantly plant-based eating pattern helps people to fill up on fiber and feel full as well as fill up on nutrients that can help them strengthen their immune systems such as eating citrus fruits, red bell peppers, spinach, broccoli, papaya, kiwi for the vitamin C, and phytonutrients. Foods with zinc, which are essential for proper immune function, include legumes, seeds, nuts, and whole grains. Patients will help themselves by eating yogurt, salmon, mushrooms, and foods fortified with vitamin D, known to help regulate the immune system and help fight infections. Sunshine is a great source of vitamin D as well. Sleeping seven to eight hours helps regulate levels of ghrelin and leptin, which can help with weight control. Lack of sleep is associated with increased calorie consumption the next day especially in the form of simple carbohydrates and hyperpalatable foods. Finally, alcohol not only adds calories to the meal but reduces inhibition making the sweet cakes, cookies, and candies easier to grab. Stress can also lead to stress eating.Learning deep breathing techniques, mindfulness-based stress reduction, meditation, and yoga can help lower levels of cortisol and reduce stress. Connecting with loved ones also helps reduce stress and combat loneliness, which is more prevalent now during the pandemic. Again, online group interventions can provide some social connection for patients.Dr. Hensrud: Weight loss during an active COVID-19 infection is not likely to be beneficial. Weight loss before developing a COVID-19 infection will obviously be beneficial. Gradual weight loss over time will reverse some of the negative metabolic consequences of obesity. However, large amounts of weight loss in a short period of time may have a negative effect on immune function.As mentioned, obesity is associated with altered immune function. Adequate micronutrient status is important for optimal immune function and an appropriate response to inflammation and infection, including viruses. There are many nutrients that are involved in these processes in the body, including zinc, selenium, omega-3 fatty acids, and vitamins C, D, and E.Randomized controlled trials of micronutrient supplementation are ongoing, but evidence from them is very limited at the present time. As in other areas of medicine, we often act with incomplete information, based on potential benefits and risks. In doing this, it is important to act with the well-known doctrine primum non nocere—first do no harm. While it may seem that treatment with micronutrients may be innocuous, historical examples such as vitamin E and beta carotene supplementation prove otherwise, as both are associated with increased mortality.Most of the current evidence relating micronutrients to COVID-19 infections relies on associations, which need to be interpreted with caution. For example, blood levels of zinc have been reported to be lower in hospitalized patients with COVID-19. However, zinc is bound to albumin, and blood levels of albumin and zinc are lower in patients with severe illness as part of the metabolic response to inflammation and infection. Thus, low zinc levels identified in many studies may not represent true zinc deficiency, which suggests treatment with zinc is less likely to be beneficial even in the face of low blood levels. Results from randomized controlled trials are needed to determine true efficacy. Findings from an early randomized open-label trial showed no benefit from vitamin C and/or zinc supplementation on duration of symptoms in SARS-CoV-2 infections.Despite the preceding context, vitamin D deserves some consideration. Vitamin D deficiency is relatively common in various populations, with 20%–50% of people exhibiting low blood levels, depending on the cutoff for "normal." In addition, vitamin D levels are lower in obese subjects and decrease with aging. Low blood values of vitamin D have been associated with COVID-19 infection, disease severity, and mortality. Vitamin D is a key regulator of the renin–angiotensin system that is an entry point of the SARS-CoV-2 virus into cells and is also involved in adequate immune function. Some nonrandomized studies have reported that vitamin D supplementation reduces the risk of COVID-19 infection and it has been suggested that a large portion of deaths from COVID-19 are due to vitamin D deficiency. The risk of vitamin D toxicity is low at usual recommended doses. Vitamin D supplementation is often recommended for the general population, particularly if low blood levels have been identified. For all these reasons, until data from clinical trials are available, it would not be unreasonable to consider vitamin D supplementation for obese and nonobese persons to prevent or treat infections with COVID-19. The optimum dose has not been determined, although a total vitamin D blood level of 30–50 ng/mL is often a target.Dr. Hart: What is being done in the integrative and lifestyle medicine communities (initiatives, education, etc.) to specifically address obesity during this pandemic?Dr. Katz: Not nearly enough. The pandemic is an overwhelming experience for all concerned, and were there to be a truly impactful "let's lose weight and find health together" campaign, it would warrant the full support of many agents, including government. As a coordinated outreach is absent, the scattered efforts of individual practitioners and entities are less apt to be a signal audible above the vast pandemic noise, and thus less prone to make a meaningful, measurable difference at scale. The epidemiologic data we have suggest weight, on average, has gone up—as Dr. Frates mentioned—not down, during the pandemic, so whatever we are doing to date, it is not nearly enough!Dr. Kushner: In July 2020, the United Kingdom Government began the Better Health campaign to target overweight and obesity in light of the ongoing COVID-19 pandemic. The free weight loss plan is meant to encourage healthier eating habits and a more active lifestyle. One change that has occurred in the United States is the growth of telehealth, which dramatically increased since March 6, 2020 when the Centers for Medicare & Medicaid Services issued site restriction waivers for reimbursement. Telehealth is more convenient for patients and eliminates the financial and time burden of traveling to the medical office. For clinicians, telehealth increases efficiency of care, reduces no-show rates, and allows for more resourceful use of office space. With good listening and communication skills, counseling can be delivered effectively, providing education, guidance, and accountability. However, it is unknown if this treatment will be effective in treating people with obesity.Dr. Frates: We need more initiatives specifically addressing obesity during this pandemic. Some steps that lifestyle medicine practitioners are taking involve writing articles for journals, contributing to health-focused websites, which are easily accessed by most of the public and crafting online health blogs. Many lifestyle medicine leaders are using social media such as Facebook, Instagram, and Twitter to spread messages about the importance of exercise, nutrition, sleep, stress reduction, social connection, and alcohol elimination or moderation. Counseling patients is still happening during the pandemic, mostly online with telemedicine. These sessions are excellent opportunities to work with patients one-on-one focusing on the six pillars, perhaps one at a time depending on a patient's readiness for change.Dr. Hensrud: It was challenging for people to manage weight before COVID-19, and has become more challenging for many people during this pandemic. More people are working at home and may be getting less low-level physical activity, compared with when they were working outside the home, and many fitness centers have closed down. Regarding diet, people may be around food more while working at home and increase their calorie intake through snacking. People who do not cook much may be increasing their calorie intake by consuming more take-out food or preparing quick comfort foods. Mental health problems have increased during COVID-19, and many mental health disorders are related to increased weight.To counteract this, some physical activity programs have gone digital to reach people in their homes. Home fitness equipment is an option, but is not available to many people and not necessary to increase physical activity. Many people have the ability to go for a walk on a regular basis, and people should take regular activity breaks when working at their computer at home. Pets have been demonstrated to increase activity, and many people have obtained a dog or cat during this pandemic.With a modest time investment, learning to cook quick healthy meals at home can help maintain weight and be an enjoyable activity. Take-out food does not have to be high in calories. Adhering to healthy dietary patterns, such as the Mediterranean diet, may potentially decrease the risk of contracting COVID-19 and improve outcomes. During COVID-19 in Italy, while many people were eating less healthy and gaining weight, greater adherence to a Mediterranean diet and lower BMI was reported in parts of the country.Some people have used this crisis as an opportunity to adopt the aforementioned behaviors, establish new habits, and manage weight even more effectively. Public health and individual health care providers can help in this effort by providing education and information on programs. However, addressing these challenges and decreasing weight will require a broad multidisciplinary approach to be effective.Dr. Hart: How can we address disparities in terms of prevalence of obesity and access to nutritional medicine, education, and healthy food?Dr. Katz: Disparities pertaining to obesity derive from disparities of education, vocation, economics, opportunity, and environment. There is no simple streamlined clinical solution for so expansive a cultural problem. But clinicians can be in the vanguard of change by providing clear and consistent guidance, and serving as clearinghouses for reliable empowering resources. There are extensive materials online to assist with eating well, ranging from recipes to food label primers to culinary medicine programming delivered live online. Much of the relevant collateral is free to the end user, so the clinician's role is to curate and recommend. Our role requires a dose of humility. If we ar