The effect of obesity on lung function

Neck circumference as reliable predictor of mechanical ventilation support in adult inpatients with COVID-19: A multicentric prospective evaluation

AIMS

COVID-19 is especially severe for elderly subjects with cardiometabolic and respiratory comorbidities. Neck circumference (NC) has been shown to be strongly related to cardiometabolic and respiratory illnesses even after adjustment for body mass index (BMI). We performed a prospective study to investigate the potential of NC to predict the need for invasive mechanical ventilation (IMV) in adult COVID-19 inpatients.

MATERIALS AND METHODS

We prospectively and consecutively enrolled COVID-19 adult patients admitted to dedicated medical wards of two Italian hospitals from 25 March to 7 April 2020. On admission, clinical, biochemical and anthropometric data, including BMI and NC were collected. As primary outcome measure, the maximum respiratory support received was evaluated. Follow-up time was 30 days from hospital admission.

RESULTS

We enrolled 132 subjects (55.0-75.8 years, 32% female). During the study period, 26 (19.7%) patients underwent IMV. In multivariable logistic regression analyses, after adjusting for age, sex, diabetes, hypertension and COPD, NC resulted independently and significantly associated with IMV risk (adjusted OR 1.260-per 1 cm increase 95% CI:1.120-1.417; P < .001), with a stronger association in the subgroup with BMI ≤30 Kg/m2 (adjusted OR 1.526; 95% CI:1.243-1.874; P < .001). NC showed a good discrimination power in predicting patients requiring IMV (AUC 0.783; 95% CI:0.684-0.882; P < .001). In particular, NC > 40.5 cm (>37.5 for females and >42.5 for males) showed a higher and earlier IMV risk compared to subjects with lower NC (Log-rank test: P < .001).

CONCLUSIONS

NC is an easy to measure parameter able to predict the need for IMV in adult COVID-19 inpatients.

The association between the level of serum 25(OH) vitamin D, obesity, and underlying diseases with the risk of developing COVID-19 infection: A case-control study of hospitalized patients in Tehran, Iran

BACKGROUND AND OBJECTIVES: The outbreak of COVID-19 has created a global public health crisis. Little is known about the predisposing factors of this infection. The aim of this study was to explore an association between the serum vitamin D level, obesity, and underlying health conditions, as well as the vulnerability to COVID-19 in the Iranian population.

METHODS

We conducted a case-control study of 201 patients with coronavirus infection and 201 controls. Cases and controls were matched for age and gender. The study was carried out for 2 months (February 2020-April 2020) at Imam Khomeini Hospital Complex, Tehran, Iran. Serum 25(OH) vitamin D was measured using the enzyme-linked immunosorbent assay method. Information containing age, gender, clinical symptoms, body mass index, computed tomography scan findings, and underlying health conditions related to each participant were elicited from health records.

RESULTS

A significant negative correlation (p = .02) was observed between the serum vitamin D level and developing coronavirus infection. Also, the results showed that the COVID-19 cases were more likely to be overweight than the controls (p = .023). Diabetes mellitus, hypertension, and respiratory infections were found in 20.89%, 9.65%, and 6.96% of cases, respectively. These underlying health conditions were not significantly different between cases and controls (p = .81).

CONCLUSIONS

Vitamin D deficiency and obesity are two main predisposing factors associated with the vulnerability to coronavirus infection in the Iranian population.

Validation and repurposing of the MSL-COVID-19 score for prediction of severe COVID-19 using simple clinical predictors in a triage setting: The Nutri-CoV score

BACKGROUND

During the COVID-19 pandemic, risk stratification has been used to decide patient eligibility for inpatient, critical and domiciliary care. Here, we sought to validate the MSL-COVID-19 score, originally developed to predict COVID-19 mortality in Mexicans. Also, an adaptation of the formula is proposed for the prediction of COVID-19 severity in a triage setting (Nutri-CoV).

METHODS

We included patients evaluated from March 16th to August 17th, 2020 at the Instituto Nacional de Ciencias Médicas y Nutrición, defining severe COVID-19 as a composite of death, ICU admission or requirement for intubation (n = 3,007). We validated MSL-COVID-19 for prediction of mortality and severe disease. Using Elastic Net Cox regression, we trained (n = 1,831) and validated (n = 1,176) a model for prediction of severe COVID-19 using MSL-COVID-19 along with clinical assessments obtained at a triage setting.

RESULTS

The variables included in MSL-COVID-19 are: pneumonia, early onset type 2 diabetes, age > 65 years, chronic kidney disease, any form of immunosuppression, COPD, obesity, diabetes, and age <40 years. MSL-COVID-19 had good performance to predict COVID-19 mortality (c-statistic = 0.722, 95%CI 0.690-0.753) and severity (c-statistic = 0.777, 95%CI 0.753-0.801). The Nutri-CoV score includes the MSL-COVID-19 plus respiratory rate, and pulse oximetry. This tool had better performance in both training (c-statistic = 0.797, 95%CI 0.765-0.826) and validation cohorts (c-statistic = 0.772, 95%CI 0.0.745-0.800) compared to other severity scores.

CONCLUSIONS

MSL-COVID-19 predicts inpatient COVID-19 lethality. The Nutri-CoV score is an adaptation of MSL-COVID-19 to be used in a triage environment. Both scores have been deployed as web-based tools for clinical use in a triage setting.

Metabolic risk factors and risk of Covid-19: A systematic review and meta-analysis

OBJECTIVE

Based on the epidemiologic findings of Covid-19 incidence; illness and mortality seem to be associated with metabolic risk factors. This systematic review and meta-analysis aimed to assess the association of metabolic risk factors and risk of Covid-19.

METHODS

This study was designed according to PRISMA guidelines. Two independent researchers searched for the relevant studies using PubMed, Web of Science, Cochrane Library, and Scopus. The search terms developed focusing on two main roots of "Covid-19" and "metabolic risk factors". All relevant observational, analytical studies, review articles, and a meta-analysis on the adult population were included in this meta-analysis. Meta-analysis was performed using the random effect model for pooling proportions to address heterogeneity among studies. Data were analyzed using STATA package version 11.2, (StataCorp, USA).

RESULTS

Through a comprehensive systematic search in the targeted databases we found 1124 papers, after running the proses of refining, 13 studies were included in the present meta-analysis. The pooled prevalence of obesity in Covid-19 patients was 29% (95% CI: 14-47%). For Diabetes and Hypertension, these were 22% (95% CI: 12% 33%) and 32% (95% CI: 12% 56%), respectively. There was significant heterogeneity in the estimates of the three pooled prevalence without any significant small-study effects. Such warning points, to some extent, guide physicians and clinicians to better understand the importance of controlling co-morbid risk factors in prioritizing resource allocation and interventions.

CONCLUSION

The meta-analysis showed that hypertension is more prevalent than obesity and diabetes in patients with Covid-19 disease. The prevalence of co-morbid metabolic risk factors must be adopted for better management and priority settings of public health vaccination and other required interventions. The results may help to improve services delivery in COVID-19 patients, while helping to develop better policies for prevention and response to COVID-19 and its critical outcomes.

Hypothesized mechanisms explaining poor prognosis in type 2 diabetes patients with COVID-19: a review

PURPOSE

Epidemiological data suggest that comorbid patients, mostly those with type 2 diabetes (T2D), are predisposed to poor prognosis in Coronavirus disease 2019 (COVID-19), leading to serious healthcare concerns. The aim of the present manuscript is to review the main relevant mechanisms possibly contributing to worsen the clinical course of COVID-19 in T2D.

RESULTS

Poor glucose control, high glycaemic variability and diabetes-related comorbidities at baseline, particularly cardiovascular diseases and obesity, contribute in worsening the prognosis in the above-mentioned cluster of patients. Moreover, both a lower efficient innate immune system response and cytokine dysregulation predispose patients with T2D to impaired viral clearance and more serious pulmonary and systemic inflammation once the SARS-CoV-2 infection occurred. Inconclusive data are currently available for specifically indicate or contraindicate concurrent medications for managing T2D and its comorbidities in infected patients.

CONCLUSIONS

T2D individuals should be considered as more vulnerable to COVID-19 than general population, and thus require adequate advices about hygienic tips to protect themselves during the pandemic. A careful management of glucose levels and diabetes-related comorbidities remains essential for avoiding further complications, and patient monitoring during the pandemic should be performed also at distance by means of telemedicine. Further studies are needed to clarify whether medications normally used for managing T2D and its associated comorbidities could have a protective or detrimental effect on COVID-19 clinical course.

Susceptibility of the obese population to COVID-19

Obesity is a risk factor for disease severity in individuals with coronavirus disease (COVID-19). However, the increased susceptibility of this population to COVID-19 is unclear. We outline several underlying mechanisms that may explain the relationship between obesity and COVID-19 severity. Obesity has an adverse effect on respiratory physiology because increased intra-abdominal adipose tissue can interfere with lung expansion, resulting in reduced lung compliance. Further, fat accumulation in the soft tissue of the pharynx can increase inspiratory resistance, and obesity may be associated with sleep apnea. Obesity is associated with several defects in cell-mediated immunity, including increased levels of pro-inflammatory cytokines. Impaired adipocyte-mediated immune function results in chronically high leptin levels, low adiponectin levels, and anti-inflammatory adipokines. Reduced physical activity can impair several steps of the immune response to viruses. Obesity also promotes a hypercoagulable state, leading to severe consequences. These factors may synergistically play a role in promoting the severity of the disease in obese individuals. A better understanding of the mechanisms by which obesity contributes to the severity of COVID-19 is important for developing more effective treatments.

Association of Long-Term Air Pollution with Prevalence and Incidence of Distal Sensorimotor Polyneuropathy: KORA F4/FF4 Study

BACKGROUND

Air pollution contributes to type 2 diabetes and cardiovascular diseases, but its relevance for other complications of diabetes, in particular distal sensorimotor polyneuropathy (DSPN), is unclear. Recent studies have indicated that DSPN is also increasingly prevalent in obesity.

OBJECTIVES

We aimed to assess associations of air pollutants with prevalent and incident DSPN in a population-based study of older individuals with high rates of type 2 diabetes and obesity.

METHODS

Cross-sectional analyses on prevalent DSPN were based on 1,075 individuals 62-81 years of age from the German Cooperative Health Research in the Region of Augsburg (KORA) F4 survey (2006-2008). Analyses on incident DSPN included 424 individuals without DSPN at baseline (KORA F4), of whom 188 had developed DSPN by the KORA FF4 survey (2013-2014). Associations of annual average air pollutant concentrations at participants' residences with prevalent and incident DSPN were estimated using Poisson regression models with a robust error variance adjusting for multiple confounders.

RESULTS

Higher particle number concentrations (PNCs) were associated with higher prevalence [risk ratio (RR) per interquartile range (IQR) increase=1.10 (95% CI: 1.01, 1.20)] and incidence [1.11 (95% CI: 0.99, 1.24)] of DSPN. In subgroup analyses, particulate (PNC, PM10, PMcoarse, PM2.5, and PM2.5abs) and gaseous (NOx, NO2) pollutants were positively associated with prevalent DSPN in obese participants, whereas corresponding estimates for nonobese participants were close to the null [e.g., for an IQR increase in PNC, RR=1.17 (95% CI: 1.05, 1.31) vs. 1.06 (95% CI: 0.95, 1.19); pinteraction=0.22]. With the exception of PM2.5abs, corresponding associations with incident DSPN were positive in obese participants but null or inverse for nonobese participants, with pinteraction≤0.13 [e.g., for PNC, RR=1.28 (95% CI: 1.08, 1.51) vs. 1.03 (95% CI: 0.90, 1.18); pinteraction=0.03].

DISCUSSION

Both particulate and gaseous air pollutants were positively associated with prevalent and incident DSPN in obese individuals. Obesity and air pollution may have synergistic effects on the development of DSPN. https://doi.org/10.1289/EHP7311.

Obesity: A critical risk factor in the COVID-19 pandemic

Obesity is an emerging independent risk factor for susceptibility to and severity of coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Previous viral pandemics have shown that obesity, particularly severe obesity (BMI > 40 kg/m2 ), is associated with increased risk of hospitalization, critical care admission and fatalities. In this narrative review, we examine emerging evidence of the influence of obesity on COVID-19, the challenges to clinical management from pulmonary, endocrine and immune dysfunctions in individuals with obesity and identify potential areas for further research. We recommend that people with severe obesity be deemed a vulnerable group for COVID-19; clinical trials of pharmacotherapeutics, immunotherapies and vaccination should prioritize inclusion of people with obesity.

Clinical characteristics of 46 pregnant women with a severe acute respiratory syndrome coronavirus 2 infection in Washington State

BACKGROUND

The impact of coronavirus disease 2019 on pregnant women is incompletely understood, but early data from case series suggest a variable course of illness from asymptomatic or mild disease to maternal death. It is unclear whether pregnant women manifest enhanced disease similar to influenza viral infection or whether specific risk factors might predispose to severe disease.

OBJECTIVE

To describe maternal disease and obstetrical outcomes associated with coronavirus disease 2019 in pregnancy to rapidly inform clinical care.

STUDY DESIGN

This is a retrospective study of pregnant patients with a laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection from 6 hospital systems in Washington State between Jan. 21, 2020, and April 17, 2020. Demographics, medical and obstetrical history, and coronavirus disease 2019 encounter data were abstracted from medical records.

RESULTS

A total of 46 pregnant patients with a severe acute respiratory syndrome coronavirus 2 infection were identified from hospital systems capturing 40% of births in Washington State. Nearly all pregnant individuals with a severe acute respiratory syndrome coronavirus 2 infection were symptomatic (93.5%, n=43) and the majority were in their second or third trimester (43.5% [n=20] and 50.0% [n=23], respectively). Symptoms resolved in a median of 24 days (interquartile range, 13-37). Notably, 7 women were hospitalized (16%) including 1 admitted to the intensive care unit. A total of 6 cases (15%) were categorized as severe coronavirus disease 2019 with nearly all patients being either overweight or obese before pregnancy or with asthma or other comorbidities. Of the 8 deliveries that occurred during the study period, there was 1 preterm birth at 33 weeks' gestation to improve pulmonary status in a woman with class III obesity, and 1 stillbirth of unknown etiology.

CONCLUSION

Severe coronavirus disease 2019 developed in approximately 15% of pregnant patients and occurred primarily in overweight or obese women with underlying conditions. Obesity and coronavirus disease 2019 may synergistically increase risk for a medically indicated preterm birth to improve maternal pulmonary status in late pregnancy. These findings support categorizing pregnant patients as a higher-risk group, particularly those with chronic comorbidities.

Correlação da força muscular respiratória com medidas antropométricas e nível de atividade física em adultos da atenção primária

RESUMO O objetivo deste estudo foi correlacionar a força muscular respiratória com as medidas antropométricas e o nível de atividade física de indivíduos adultos da atenção primária. Trata-se de um estudo transversal, realizado em uma unidade básica de saúde, onde foram incluídos indivíduos de ambos os sexos e com idade superior a 18 anos. A força muscular respiratória foi analisada pela pressão inspiratória máxima (PImáx) e pressão expiratória máxima (PEmáx), por meio do manovacuômetro, onde valores pressóricos acima de 80% em relação ao predito foram considerados normais. Utilizou-se balança mecânica, estadiômetro e fita métrica para mensuração das principais medidas antropométricas: índice de massa corporal (IMC), circunferência de pescoço (CP), circunferência abdominal (CA), circunferência de quadril (CQ), relação cintura-quadril (RCQ) e o índice de adiposidade corporal (IAC). O nível de atividade física foi determinado pelo questionário internacional de atividade física (IPAQ), onde os indivíduos foram categorizados como sedentário, irregularmente ativo A, irregularmente ativo B, ativo ou muito ativo, sendo realizada também a estimativa dos equivalentes metabólicos (MET) alcançados. Foram avaliados 110 indivíduos adultos (78,1% do sexo feminino; 51,9±12,3 anos), e com porcentagem em relação ao predito (%) de PImáx de 96,3±32,4% e 98,9±27,3% de PEmáx. A %PImáx apresentou fraca correlação com o IAC (r=0,23; p=0,01) e com a CQ (r=0,20; p=0,03), e a %PEmáx com o IMC (r=0,26; p<0,01) e IAC (r=0,30; p<0,01). Não houve diferença dos valores médios de %PImáx (p=0,61) e %PEmáx (p=0,54) entre as categorias do IPAQ, além de não existirem correlações (p>0,05) com os MET estimados. Em adultos da atenção primária, a força muscular respiratória apresentou fraca correlação com IMC, CQ e IAC, porém sem correlação com o nível de atividade física.

Obesity and the Lung: What We Know Today

Obesity is becoming more and more prevalent especially in Western industrial nations. The understanding of adipose tissue as an endocrine organ as well as the detection of adipocytokines - hormones that are secreted from the adipose tissue - gave reason to examine the interactions between adipose tissue and target organs. These efforts have been intensified especially in the context of bariatric surgery as promising weight loss therapy. Interactions between the lung and adipose tissue have rarely been investigated and are not well understood. There are obvious mechanical effects of obesity on lung function explaining the associations between obesity and lung diseases, in particular obesity hypoventilation syndrome, obstructive sleep apnea syndrome, asthma, and chronic obstructive pulmonary disease. The rise in the prevalence of obesity affects the epidemiology of pulmonary diseases as well. The aim of this review is to summarize the current knowledge on interactions, associations, and consequences of obesity and weight loss on lung function and lung diseases. Based on these data, areas for future research are identified.

The Impact of Previous History of Bariatric Surgery on Outcome of COVID-19. A Nationwide Medico-Administrative French Study

Purpose

To determine the risk of invasive mechanical ventilation and death in obese individuals with a history of bariatric surgery (BS) admitted for COVID-19.

Methods

All obese inpatients recorded during a hospital stay by the French National Health Insurance were included, and their electronic health data were reviewed retrospectively. Patients who had undergone bariatric surgery comprised the BS group and patients with obesity but no history of BS served as controls. The primary outcome was COVID-19-related death and the secondary outcome was the need for invasive mechanical ventilation.

Results

4,248,253 obese individuals aged 15–75 years were included and followed for a mean observation time of 5.43 ± 2.93 years. 8286 individuals with a previous diagnosis of obesity were admitted for COVID-19 between January 1 and May 15, 2020. Of these patients, 541 had a history of BS and 7745 did not. The need for invasive mechanical ventilation and death occurred in 7% and 3.5% of the BS group versus 15% and 14.2% of the control group, respectively. In logistic regression, the risk of invasive mechanical ventilation was independently associated with increasing age, male sex, and hypertension, and mortality was independently associated with increasing age, male sex, history of heart failure, cancer, and diabetes, whereas BS had an independent protective effect. Two random exact matching tests confirmed the protective effect of BS.

Conclusion

This nationwide study showed that BS is independently associated with a reduced risk of death and invasive mechanical ventilation in obese individuals with COVID-19.

COVID-19 and Cardiovascular Comorbidities

The emergence of a new coronavirus - severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) - has resulted in a global pandemic. The associated coronavirus disease 2019 (COVID-19) has resulted in a high number of death worldwide. Observational studies and case reports have provided insights that older age and the presence of chronic diseases is frequently associated with a higher COVID-19 severity. These individuals also seem to have a higher risk of mortality due to COVID-19. In this review we provide insights into the impact chronic diseases associated with the cardiovascular system, such as obesity, diabetes mellitus, hypertension and cardiovascular disease might have on SARS-CoV-2 infection and COVID-19. Additionally we review recommendations and guidance's of international scientific associations and discuss which key learnings might be of importance for the future.

Obesity population at risk of COVID-19 complications

Introduction

Global public health is challenged by two concurrent epidemics; COVID-19 and obesity. Considering the global prevalence of obesity, exploring relationships with COVID-19 are of clinical importance. The aim was to provide a comprehensive summary and recommendations on this relationship between COVID-19 and obesity.

Method

A literature search was performed to prepare a narrative review of COVID-19 and obesity.

Results

An obesity state promotes chronic inflammation, vitamin D deficiency, hinders immunity and causes mechanical lung compression. These increase susceptibilities to COVID-19 infection, complications including the requirement of invasive ventilation. Existing co-morbidities enhances these complications. Preventive measures of social distancing and self-isolation may increase stigmatisation and psychological deterrents. Hence, special recommendations targeting this vulnerable population are required.

Conclusion

The obese population is a COVID-19 vulnerable group, requiring special attention during this pandemic to avoid complications and healthcare systems burden. Lacking COVID-19 vaccination, regular physical activity and a healthy diet are recommended with attention to mental health. A prolonged quarantine duration and administration of prophylactic vitamin D may be considered.

Effect of increased BMI and obesity on the outcome of COVID-19 adult patients: A systematic review and meta-analysis

BACKGROUND AND AIMS

Corona virus diseases 2019 (COVID-19) pandemic spread rapidly. Growing evidences that overweight and obesity which extent nearly a third of the world population were associated with severe COVID-19. This study aimed to explore the association and risk of increased BMI and obesity with composite poor outcome in COVID-19 adult patients.

METHODS

We conducted a systematic literature search from PubMed and Embase database. We included all original research articles in COVID-19 adult patients and obesity based on classification of Body Mass Index (BMI) and composite poor outcome which consist of ICU admission, ARDS, severe COVID-19, use of mechanical ventilation, hospital admission, and mortality.

RESULTS

Sixteen studies were included in meta-analysis with 9 studies presented BMI as continuous outcome and 10 studies presented BMI as dichotomous outcome (cut-off ≥30 kg/m²). COVID-19 patients with composite poor outcome had higher BMI with mean difference 1.12 (95% CI, 0.67-1.57, P < 0.001). Meanwhile, obesity was associated with composite poor outcome with odds ratio (OR) = 1.78 (95% CI, 1.25-2.54, P < 0.001) Multivariate meta-regression showed the association between BMI and obesity on composite poor outcome were affected by age, gender, DM type 2, and hypertension.

CONCLUSION

Obesity is a risk factor of composite poor outcome of COVID-19. On the other hand, COVID-19 patients with composite poor outcome have higher BMI. BMI is an important routine procedure that should always be assessed in the management of COVID-19 patients and special attention should be given to patients with obesity.

Obesity as a contributor to immunopathology in pregnant and non-pregnant adults with COVID-19

The ongoing coronavirus disease 2019 (COVID-19) pandemic has led to a global public health emergency with the need to identify vulnerable populations who may benefit from increased screening and healthcare resources. Initial data suggest that overall, pregnancy is not a significant risk factor for severe coronavirus disease 2019 (COVID-19). However, case series have suggested that maternal obesity is one of the most important comorbidities associated with more severe disease. In obese individuals, suppressors of cytokine signaling are upregulated and type I and III interferon responses are delayed and blunted leading to ineffective viral clearance. Obesity is also associated with changes in systemic immunity involving a wide range of immune cells and mechanisms that lead to low-grade chronic inflammation, which can compromise antiviral immunity. Macrophage activation in adipose tissue can produce low levels of pro-inflammatory cytokines (TNF-α, IL-1β, IL-6). Further, adipocyte secretion of leptin is pro-inflammatory and high circulating levels of leptin have been associated with mortality in patients with acute respiratory distress syndrome. The synergistic effects of obesity-associated delays in immune control of COVID-19 with mechanical stress of increased adipose tissue may contribute to a greater risk of pulmonary compromise in obese pregnant women. In this review, we bring together data regarding obesity as a key co-morbidity for COVID-19 in pregnancy with known changes in the antiviral immune response associated with obesity. We also describe how the global burden of obesity among reproductive age women has serious public health implications for COVID-19.

Characteristics of patients with diabetes hospitalised for COVID-19 infection-a brief case series report

OBJECTIVES

Diabetes has been shown to be a risk factor for corona virus disease-2019 (COVID-19) infection. The characteristics of patients with diabetes vulnerable to this infection are less specified. We aim to present the characteristics of patients with diabetes admitted to hospital with COVID-19.

DESIGN

A retrospective case series.

SETTING

A single clinical centre in the UK.

METHODS

We have retrospectively collected the demographics, medical characteristics and outcome of all patients with diabetes admitted to hospital over two-week period with COVID-19 infection. All cases were diagnosed by a reverse transcription polymerase chain reaction (RT-PCR) of pharyngeal and nasal swabs.

RESULTS

A total of 71 COVID-19 patients were admitted during the study period of whom 16 (22.5%) patients had diabetes and were included in this case series. There was no significant difference between patients with compared to those without diabetes regarding age, gender or clinical presentation. However, comorbidities were more common in patients with diabetes specially hypertension {75% v 36.4%, a difference of 38.6%, 95% confidence interval (CI) 6.5-58.3} and chronic kidney disease (37.5 v 5.5, a difference of 32% (1.6-51.6). Patients with diabetes were significantly more obese than those without diabetes (56.2% v 21.8% a difference of 34.4%, 95% CI 7.7-61.1). About one third (31.3%) of patients with diabetes were frail. Mean {standard deviation (SD)} duration of diabetes was 10 (2.8) years and mean (SD) HbA1c was 60.3 (15.6) mmol/mol. The use of angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) and non-steroidal anti-inflammatory drugs (NSAIDs) was common (37.5%, 25% and 18.8% respectively). There was no significant difference in the outcomes between patients with compared to those without diabetes.

CONCLUSION

Patients with diabetes hospitalised for COVID-19 were significantly more obese and had high prevalence of comorbidities than those without diabetes. Other features of patients with diabetes and COVID-19 infection included long duration of diabetes, less tight glycaemic control and common use of ACE inhibitors, ARBs and NSAIDs.

The Effect of Adiposity Markers on Fractional Exhaled Nitric Oxide (FeNO) and Pulmonary Function Measurements

Background

The effect of increasing body weight on pulmonary function and the fractional exhaled nitric oxide (FeNO) remains controversial and the role of different body compositions in the relationship between obesity with pulmonary function and FeNO is still unrevealed. Thus, we aim to determine the effect of overweight/obesity on lung function and FeNO, focusing on the relationship with different body compositions.

Methods

Eighty-two non-smoker students (20 ± 1.9 years) were divided into two groups: 38 subjects with normal weight (BMI = 18.5–24.99) and 44 overweight/obese subjects (BMI ≥ 25). Spirometric parameters and FeNO were measured and compared between groups and were correlated with different adiposity markers.

Results

FeNO measurements were elevated in the overweight/obese group [median (IQR) 19.5 (13)] in comparison to the normal weight group [11 (10), p value = 0.017]. A positive correlation was found between FeNO measurements and body mass index (BMI), waist circumference, hip circumference, waist-hip ratio, and visceral fat percentage (all p values < 0.01). The absolute values of forced vital capacity (FVC) forced expiratory volume in the first second (FEV₁), peak expiratory flow (PEF), forced expiratory flow during mid-expiration (FEF_25–75%), and FEV₁/FVC ratio showed no significant differences between groups. However, the percentage of the predicted values of FEV₁ and FVC was significantly higher and the value of percentage predicted FEF_25–75% was reduced significantly in the overweight/obese subjects.

Conclusion

Increase in BMI could significantly increase airway inflammation as measured by FeNO, as well as on distal airway function as determined by the percentage predicted values of FEF_25–75%. A significant correlation was also identified between visceral fat and FeNO measurement.

The Association Between BMI and Inpatient Mortality Outcomes in Older Adults With COVID-19

Background and aim

Coronavirus disease 2019 (COVID-19) is known to cause a broad spectrum of illnesses. There is evidence that obesity-related conditions may increase the severity of COVID-19 disease, especially in those below the age of 60. However, there has been limited research on mortality rate based on body mass index (BMI) in the older adult population, defined as age over 65. The objective of this study was to characterize outcomes in older adults infected with COVID-19 based on BMI.

Study design and methods

It is a single-center retrospective cohort study of older adults with COVID-19 infection. The primary outcome was hospital mortality. Secondary outcomes assessed were oxygen requirements, need for mechanical ventilation, duration of mechanical ventilation, and hospital length of stay. Data were analyzed with the Student’s t-test, Fisher’s exact test, and multiple logistic regression analyses as appropriate.

Results

A total of 290 patients were included in this study. The mean age was 77.6 years. The median BMI was >30 kg/m2. The primary outcome of hospital mortality occurred in 49.7% of patients. BMI was not found to be a predictor of mortality. Age 75-79 and age ≥ 85 were associated with an increased risk of mortality (OR: 2.58; 95% CI: 1.15 - 5.79; OR: 3.17; 95% CI: 1.35 - 7.44, respectively). Patients with a BMI < 18.5, BMI 18.5 - 25, and age ≥ 85 were less likely to require mechanical ventilation (OR: 0.06; 95% CI: 0.00 - 0.83; OR:0.11; 95% CI: 0.02 - 0.64 and OR:0.28; 95% CI: 0.09 - 0.92, respectively). Past medical history was not associated with mortality.

Conclusion

In a cohort of older adults with COVID-19 disease, BMI was not an independent predictor of in-hospital mortality. Patients with BMI ≤ 25 and age ≥ 85 years were less likely to require mechanical ventilation.

Clinical Impact Potential of Supplemental Nutrients as Adjuncts of Therapy in High-Risk COVID-19 for Obese Patients

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) in China at the end of 2019 caused a major global pandemic and continues to be an unresolved global health crisis. The supportive care interventions for reducing the severity of symptoms along with participation in clinical trials of investigational treatments are the mainstay of COVID-19 management because there is no effective standard therapy for COVID-19. The comorbidity of COVID-19 rises in obese patients. Micronutrients may boost the host immunity against viral infections, including COVID-19. In this review, we discuss the clinical impact potential of supplemental nutrients as adjuncts of therapy in high-risk COVID-19 for obese patients.

Effect of Body Mass Index on Lung Function in Chinese Patients with Chronic Obstructive Pulmonary Disease: A Multicenter Cross-Sectional Study

Objective

The aim of this study was to explain “obesity paradox” in chronic obstructive pulmonary disease (COPD) by evaluating the effect of body mass index (BMI) on lung function in Chinese patients with COPD.

Methods

A total of 1644 patients diagnosed with COPD were recruited from four Chinese tertiary hospitals and were divided into four groups including underweight, normal weight, overweight and obese according to BMI classification standard. The medical data of these patients were collected and used for the multiple linear regression analyses.

Results

After adjustment for age, sex, educational level, economic status, smoking status, alcohol consumption, duration of COPD history, events of acute exacerbation in previous year, hypertension, diabetes mellitus, cardiovascular disease, cerebrovascular disease and osteoporosis, BMI had a curvilinear correlation with the forced expiratory volume in the first second (FEV₁) in patients with Global Initiative for Obstructive Lung Disease (GOLD) 1–2 grade (first-order coefficient β, 0.09; 95% CI, 0.03–0.16; second-order coefficient β, −0.002; 95% CI, −0.003–-0.001; P<0.01). However, BMI had a positive correlation with FEV₁ in patients with GOLD 3–4 grade (β, 0.01; 95% CI, 0.008–0.017; P<0.01) when BMI was used as a quantitative variable. When BMI was used as a qualitative variable, only FEV₁ in overweight group with GOLD 1–2 grade was significantly higher than that of normal weight group (P<0.01). Interestingly, both overweight and obese groups had higher FEV₁ in GOLD 3–4 grade compared with normal weight group (β, 0.06; 95% CI, 0.02–0.11; β, 0.11; 95% CI, 0.04–0.18; P<0.01). The effect of BMI on predicted percentage of FEV₁ (FEV₁%) was similar to that of FEV₁ in different GOLD grades.

Conclusion

Obesity only had a protective effect on lung function in COPD patients with GOLD 3–4 grade rather than GOLD 1–2 grade.

Trial Registry

ClinicalTrials.gov, No.: NCT 03182309, URL: www.clinicaltrials.gov.

Allergic sensitization to peanuts is enhanced in mice fed a high-fat diet

The incidence of peanut (PN) allergy is on the rise. As peanut allergy rates have continued to climb over the past few decades, obesity rates have increased to record highs, suggesting a link between obesity and the development of peanut allergy. While progress has been made, much remains to be learned about the mechanisms driving the development of allergic immune responses to peanut. Remaining unclear is whether consuming a Western diet, a diet characterized by overeating foods rich in saturated fat, salt, and refined sugars, supports the development of PN allergy. To address this, we fed mice a high fat diet to induce obesity. Once diet-induced obesity was established, mice were exposed to PN flour via the airways using our 4-week inhalation model. Mice were subsequently challenged with PN extract to induce anaphylaxis. Mice fed a high-fat diet developed significantly higher titers of PN-specific IgE, as well as stronger anaphylactic responses, when compared to their low-fat diet fed counterparts. These results suggest that obesity linked to eating a high-fat diet promotes the development of allergic immune responses to PN in mice. Such knowledge is critical to advance our growing understanding of the immunology of PN allergy.

A, Birangal SR, Nikam AN, Pandey A, Mutalik S, Joseph A. Role of comorbidities like diabetes on severe acute respiratory syndrome coronavirus-2: A review

Pandemic coronavirus disease-2019, commonly known as COVID-19 caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a highly contagious disease with a high mortality rate. Various comorbidities and their associated symptoms accompany SARS-CoV-2 infection. Among the various comorbidities like hypertension, cardiovascular disease and chronic obstructive pulmonary disease, diabetes considered as one of the critical comorbidity, which could affect the survival of infected patients. The severity of COVID-19 disease intensifies in patients with elevated glucose level probably via amplified pro-inflammatory cytokine response, poor innate immunity and downregulated angiotensin-converting enzyme 2. Thus, the use of ACE inhibitors or angiotensin receptor blockers could worsen the glucose level in patients suffering from novel coronavirus infection. It also observed that the direct β-cell damage caused by virus, hypokalemia and cytokine and fetuin-A mediated increase in insulin resistance could also deteriorate the diabetic condition in COVID-19 patients. This review highlights the current scenario of coronavirus disease in pre-existing diabetic patients, epidemiology, molecular perception, investigations, treatment and management of COVID-19 disease in patients with pre-existing diabetes. Along with this, we have also discussed unexplored therapies and future perspectives for coronavirus infection.

Obesity is Associated with Increased Risk for Mortality Among Hospitalized Patients with COVID-19

OBJECTIVE

Obesity has been identified as a risk factor for severe coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 virus. This study sought to determine whether obesity is a risk factor for mortality among patients with COVID-19.

METHODS

The study was a retrospective cohort that included patients with COVID-19 between March 1 and April 18, 2020.

RESULTS

A total of 238 patients were included; 218 patients (91.6%) were African American, 113 (47.5%) were male, and the mean age was 58.5 years. Of the included patients, 146 (61.3%) had obesity (BMI > 30 kg/m² ), of which 63 (26.5%), 29 (12.2%), and 54 (22.7%) had class 1, 2, and 3 obesity, respectively. Obesity was identified as a predictor for mortality (odds ratio [OR] 1.7 [1.1-2.8], P = 0.016), as was male gender (OR 5.2 [1.6-16.5], P = 0.01) and older age (OR 3.6 [2.0-6.3], P < 0.0005). Obesity (OR 1.7 [1.3-2.1], P < 0.0005) and older age (OR 1.3 [1.0-1.6], P = 0.03) were also risk factors for hypoxemia.

CONCLUSIONS

Obesity was found to be a significant predictor for mortality among inpatients with COVID-19 after adjusting for age, gender, and other comorbidities. Patients with obesity were also more likely to present with hypoxemia.

Metabolic Syndrome and Incident Asthma in Chinese Adults: An Open Cohort Study

BACKGROUND

Although metabolic syndrome is awell-known risk factor for many non-communicable diseases, its contribution to asthma remains controversial.

OBJECTIVE

The aim of this study was to explore the associations of metabolic syndrome and its components with incident asthma in Chinese adults.

METHODS

We conducted an open cohort study of participants who were asthma-free at baseline (n=42,304) in the Shandong multi-center health check-up longitudinal study from 2004 to 2015. Participants aged ≥20 years and had regular physical examination (once ayear) more than three times during follow-up.

RESULTS

Ninety subjects (38 women and 52 men) developed incident asthma over 12 years of follow-up. Our study suggested that metabolic syndrome itself was not significantly associated with incident asthma in either women or men (P>0.050). Interestingly, we found that overweight and/or obesity was arisk factor for incident asthma among women but not men in the Cox proportional hazards model after adjusting covariates (adjusted incidence rate ratio (IRR)= 2.940, 95% confidence interval (CI): 1.467-5.894, P=0.002). The result was consistent with the Poisson regression model (hazard ratio (HR)= 2.241, 95% CI: 1.135-4.988, P=0.026). After stratifying according to overweight and/or obesity, we found that female subjects with overweight and obesity were associated with the occurrence of incident asthma (P<0.050). However, we did not find this result among men.

CONCLUSION

Metabolic syndrome was not significantly associated with incident asthma in both women and men; however, overweight and/or obesity was shown to be asignificant risk factor for incident asthma but only in women, not in men.

Adjunct low level laser therapy (LLLT) in a morbidly obese patient with severe COVID-19 pneumonia: A case report

Introduction

COVID-19 poses a higher risk of complications in obese patients due to low respiratory system compliance, increased inflammatory cytokines, and an activated immune system secondary to excess adiposity. Low level laser therapy (LLLT) has significant anti-inflammatory effects and reduces inflammatory cytokines. It is noninvasive and approved for pain management and musculoskeletal injuries. Data from human and experimental animal models of respiratory tract disease suggests that LLLT reduces inflammation and promotes lung healing.

Case and outcomes

A morbidly obese 32-year-old Asian female with severe COVID-19 received four consecutive once-daily LLLT sessions via a laser scanner. Pulsed 808 nm and 905 nm laser beams were delivered over the posterior chest for 28 min. The patient was evaluated before and after LLLT by radiological assessment of lung edema (RALE) on chest X-ray, oxygen requirements and saturation, pneumonia severity indices (SMART-COP and Brescia-COVID), blood inflammatory markers (interleukin-6, ferritin, and C-Reactive protein (CRP)). Prior to treatment, oxygen saturation (SpO₂) via pulse oximetry was 88%–93% on 5–6 L oxygen. Following LLLT, SpO₂ increased to 97%–99% on 1–3 L oxygen. Reductions in RALE score from 8 to 3, Brescia-COVID from 4 to 0, and SMART-COP from 5 to 0 were observed. Interleukin-6 decreased from 45.89 to 11.7 pg/mL, ferritin from 359 to 175 ng/mL, and CRP from 3.04 to 1.43 mg/dL. Post-treatment, the patient noted appreciable improvement in respiratory symptoms.

Conclusion

Following LLLT our patient showed improvement over a few days in respiratory indices, radiological findings, inflammatory markers, and patient outcomes. This report suggests that adjunct LLLT can be safely combined with conventional treatment in patients with severe COVID-19 and morbid obesity.

Reverse J-shaped relationship between body mass index and in-hospital mortality of patients hospitalized for heart failure in Japan

Several lines of evidence demonstrated body mass index (BMI) to be inversely associated with outcomes of patients with HF, so-called obesity paradox. However, the relationship between BMI and outcomes of patients with HF in Japan has been poorly understood. This study sought to explore the relationship between BMI and in-hospital mortality of patients hospitalized for heart failure (HF) in Japan and whether BMI at hospital admission could be used for the risk stratification of hospitalized HF patients. We studied 407,722 patients hospitalized for HF between January 2010 and March 2018, using the Diagnosis Procedure Combination database, a national inpatient database in Japan. Patients were categorized into four groups: underweight (BMI < 18.5 kg/m²), 66,342 patients (16.3%); normal (18.5-24.9 kg/m²), 240,801 patients (59.1%); pre-obesity (25.0-29.9 kg/m²), 76,954 patients (18.9%); and obesity (≥ 30.0 kg/m²), 23,625 patients (5.8%). Pre-obese and obese patients were younger and more likely to be male. Advanced HF symptoms were more common among underweight patients. Multivariable logistic regression analysis fitted with generalized estimating equation showed that, compared with normal weight patients underweight patients had higher in-hospital mortality (odds ratio 1.50, 95% confidence interval 1.45-1.55), whereas pre-obese patients (odds ratio 0.80, 95% confidence interval 0.77-0.83) and obese patients (odds ratio 0.90, 95% confidence interval 0.84-0.97) had lower in-hospital mortality. Restricted cubic spline showed a reverse J-shaped relationship between BMI and in-hospital mortality with the bottoms of splines around BMI 26 kg/m². In conclusion, underweight patients had higher, and pre-obese and obese patients had lower in-hospital mortality compared to patients with normal weight patients. Furthermore, restricted cubic spline indicated a reverse J-shaped relationship between BMI and in-hospital mortality. Our findings are informative for the risk stratification of patients hospitalized for HF according to BMI.

Coronavirus disease 2019 (COVID-19) and obesity. Impact of obesity and its main comorbidities in the evolution of the disease

The COVID-19 pandemic is posing a great challenge worldwide. Its rapid progression has caused thousands of deaths worldwide. Although multiple aspects remain to be clarified, some risk factors associated with a worse prognosis have been identified. These include obesity and some of its main complications, such as diabetes and high blood pressure. Furthermore, although the possible long-term complications and psychological effects that may appear in survivors of COVID-19 are not well known yet, there is a concern that those complications may be greater in obese patients. In this manuscript, we review some of the data published so far and the main points that remain to be elucidated are emphasized.

Should patients with obesity be more afraid of COVID-19?

COVID-19 crisis has lasted since the late 2019 to the present day. The severity of the disease is positively correlated with several factors, such as age and coexisting diseases. Furthermore, obesity is increasingly considered as a yet another risk factor, particularly, because it has been observed that people suffering from excessive body weight may experience a more severe course of COVID-19 infection. On the basis of current research, in our nonsystematic review, we have investigated the extent to which obesity can affect the SARS-CoV-2 course and identify the potential mechanisms of the disease. We have also described the role of proper nutrition, physical activity and other aspects relevant to the management of obesity.

Maximum Phonation Time Normative Values Among Malaysians and Its Relation to Body Mass Index

OBJECTIVE

Maximum phonation time (MPT) is a test to measure glottic efficiency for laryngeal pathology screening and treatment monitoring. The normative value of MPT for South East Asia population has yet to be reported. It is postulated that MPT may be affected by body mass index (BMI) despite the paucity of evidence. Therefore, this study was designed to establish the normative value of MPT for a South East Asia population and investigate its relation to BMI.

DESIGN & SETTING

This cross-sectional study was conducted in Universiti Kebangsaan Malaysia Medical Center between May and September 2017.

PARTICIPANTS AND METHODS

Three hundred males and females with mean age of 30.23 (±11.04) years were recruited in equal number for each gender (n = 150) and divided into 3 groups of 50 according to their BMI (n = 50). The three groups are non-obese (BMI≤22.9kg/m²); obese (BMI between 23 and 34.9 kg/m²); and morbidly obese (BMI >35kg/m²). BMI and Voice Handicap Index-10 (VHI-10) were obtained. The average of three readings of MPT was measured using a stopwatch while the participants phonate /a/, /i/ and /u/. Unpaired t-test and ANOVA were used to compare means between and across groups. Spearman correlation assessed the correlation between MPT and BMI.

MAIN OUTCOME MEASURES

The normative values of MPT of both genders and correlation with BMI were analyzed.

RESULTS

The MPT normative values for males and females in the non-obese group were of 21.41 (±6.85) seconds and 18.05 (±5.06)seconds respectively for /a/. The MPT for all vowels were significantly higher in males across the BMI groups (P ≤ 0.05). There was low negative correlation between MPT and BMI in both genders.

CONCLUSIONS

This pioneering study documented the normative values of MPT among Malaysians showed that males had longer MPT than females across the BMI groups. Obesity affects the MPT in that as BMI increases, the MPT decreases.

The hidden role of NLRP3 inflammasome in obesity-related COVID-19 exacerbations: Lessons for drug repurposing

COVID-19, the illness caused by SARS-CoV-2, has a wide-ranging clinical spectrum that, in the worst-case scenario, involves a rapid progression to severe acute respiratory syndrome and death. Epidemiological data show that obesity and diabetes are among the main risk factors associated with high morbidity and mortality. The increased susceptibility to SARS-CoV-2 infection documented in obesity-related metabolic derangements argues for initial defects in defence mechanisms, most likely due to an elevated systemic metabolic inflammation ("metaflammation"). The NLRP3 inflammasome is a master regulator of metaflammation and has a pivotal role in the pathophysiology of either obesity or diabetes. Here, we discuss the most recent findings suggesting contribution of NLRP3 inflammasome to the increase in complications in COVID-19 patients with diabesity. We also review current pharmacological strategies for COVID-19, focusing on treatments whose efficacy could be due, at least in part, to interference with the activation of the NLRP3 inflammasome. LINKED ARTICLES: This article is part of a themed issue on The Pharmacology of COVID-19. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v177.21/issuetoc.

Does Sars-Cov-2 threaten our dreams? Effect of quarantine on sleep quality and body mass index

Background

COVID 19-related quarantine led to a sudden and radical lifestyle changes, in particular in eating habits. Objectives of the study were to investigate the effect of quarantine on sleep quality (SQ) and body mass index (BMI), and if change in SQ was related to working modalities.

Materials

We enrolled 121 adults (age 44.9 ± 13.3 years and 35.5% males). Anthropometric parameters, working modalities and physical activity were studied. Sleep quality was evaluated by the Pittsburgh Sleep Quality Index (PSQI) questionnaire. At baseline, the enrolled subjects were assessed in outpatient clinic and after 40 days of quarantine/lockdown by phone interview.

Results

Overall, 49.6% of the subjects were good sleepers (PSQI < 5) at the baseline and significantly decreased after quarantine (p < 0.001). In detail, sleep onset latency (p < 0.001), sleep efficiency (p = 0.03), sleep disturbances (p < 0.001), and daytime dysfunction (p < 0.001) significantly worsened. There was also a significant increase in BMI values in normal weight (p = 0.023), in subjects grade I (p = 0.027) and II obesity (p = 0.020). In all cohort, physical activity was significantly decreased (p = 0.004). However, analyzing the data according gender difference, males significantly decreased physical activity as well as females in which there was only a trend without reaching statistical significance (53.5% vs 25.6%; p = 0.015 and 50.0% vs 35.9%, p = 0.106; in males and females, respectively). In addition, smart working activity resulted in a significant worsening of SQ, particularly in males (p < 0.001).

Conclusions

Quarantine was associated to a worsening of SQ, particularly in males doing smart working, and to an increase in BMI values.

Obesity and COVID-19: Molecular Mechanisms Linking Both Pandemics

The coronavirus disease 2019 COVID-19 pandemic is rapidly spreading worldwide and is becoming a major public health crisis. Increasing evidence demonstrates a strong correlation between obesity and the COVID-19 disease. We have summarized recent studies and addressed the impact of obesity on COVID-19 in terms of hospitalization, severity, mortality, and patient outcome. We discuss the potential molecular mechanisms whereby obesity contributes to the pathogenesis of COVID-19. In addition to obesity-related deregulated immune response, chronic inflammation, endothelium imbalance, metabolic dysfunction, and its associated comorbidities, dysfunctional mesenchymal stem cells/adipose-derived mesenchymal stem cells may also play crucial roles in fueling systemic inflammation contributing to the cytokine storm and promoting pulmonary fibrosis causing lung functional failure, characteristic of severe COVID-19. Moreover, obesity may also compromise motile cilia on airway epithelial cells and impair functioning of the mucociliary escalators, reducing the clearance of severe acute respiratory syndrome coronavirus (SARS-CoV-2). Obese diseased adipose tissues overexpress the receptors and proteases for the SARS-CoV-2 entry, implicating its possible roles as virus reservoir and accelerator reinforcing violent systemic inflammation and immune response. Finally, anti-inflammatory cytokines like anti-interleukin 6 and administration of mesenchymal stromal/stem cells may serve as potential immune modulatory therapies for supportively combating COVID-19. Obesity is conversely related to the development of COVID-19 through numerous molecular mechanisms and individuals with obesity belong to the COVID-19-susceptible population requiring more protective measures.

Predicting Mortality Due to SARS-CoV-2: A Mechanistic Score Relating Obesity and Diabetes to COVID-19 Outcomes in Mexico

BACKGROUND

The SARS-CoV-2 outbreak poses a challenge to health care systems due to its high complication rates in patients with cardiometabolic diseases. Here, we identify risk factors and propose a clinical score to predict COVID-19 lethality, including specific factors for diabetes and obesity, and its role in improving risk prediction.

METHODS

We obtained data of confirmed and negative COVID-19 cases and their demographic and health characteristics from the General Directorate of Epidemiology of the Mexican Ministry of Health. We investigated specific risk factors associated to COVID-19 positivity and mortality and explored the impact of diabetes and obesity on modifying COVID-19-related lethality. Finally, we built a clinical score to predict COVID-19 lethality.

RESULTS

Among the 177 133 subjects at the time of writing this report (May 18, 2020), we observed 51 633 subjects with SARS-CoV-2 and 5,332 deaths. Risk factors for lethality in COVID-19 include early-onset diabetes, obesity, chronic obstructive pulmonary disease, advanced age, hypertension, immunosuppression, and chronic kidney disease (CKD); we observed that obesity mediates 49.5% of the effect of diabetes on COVID-19 lethality. Early-onset diabetes conferred an increased risk of hospitalization and obesity conferred an increased risk for intensive care unit admission and intubation. Our predictive score for COVID-19 lethality included age ≥ 65 years, diabetes, early-onset diabetes, obesity, age < 40 years, CKD, hypertension, and immunosuppression and significantly discriminates lethal from non-lethal COVID-19 cases (C-statistic = 0.823).

CONCLUSIONS

Here, we propose a mechanistic approach to evaluate the risk for complications and lethality attributable to COVID-19, considering the effect of obesity and diabetes in Mexico. Our score offers a clinical tool for quick determination of high-risk susceptibility patients in a first-contact scenario.

Small airway function in obese individuals with self-reported asthma

Diagnosis of asthma in obese individuals frequently relies on clinical history, as airflow by spirometry may remain normal. This study hypothesised that obese subjects with self-reported asthma and normal spirometry will demonstrate distinct clinical characteristics, metabolic comorbidities and enhanced small airway dysfunction as compared with healthy obese subjects. Spirometry, plethysmography and oscillometry data pre/post-bronchodilator were obtained in 357 obese subjects in three groups as follows: no asthma group (n=180), self-reported asthma normal spirometry group (n=126), and asthma obstructed spirometry group (n=51). To assess the effects of obesity related to reduced lung volume, oscillometry measurements were repeated during a voluntary inflation to predicted functional residual capacity (FRC). Dyspnoea was equally prevalent in all groups. In contrast, cough, wheeze and metabolic comorbidities were more frequent in the asthma normal spirometry and asthma obstructed spirometry groups versus the no asthma group (p<0.05). Despite similar body size, oscillometry measurements demonstrated elevated R _5-20 (difference between resistance at 5 and 20 Hz) in the no asthma and asthma normal spirometry groups (0.19±0.12; 0.23±0.13 kPa/(L·s^-1), p<0.05) but to a lesser degree than the asthma obstructed spirometry group (0.34±0.20 kPa/(L·s^-1), p<0.05). Differences between groups persisted post-bronchodilator (p<0.05). Following voluntary inflation to predicted FRC, R _5-20 in the no asthma and asthma normal spirometry groups fell to similar values, indicating a reversible process (0.11±0.07; 0.12±0.08 kPa/(L·s^-1), p=NS). Persistently elevated R _5-20 was seen in the asthma obstructed spirometry group, suggesting chronic inflammation and/or remodelling (0.17±0.11 kPa/(L·s^-1), p<0.05). Thus, small airway abnormalities of greater magnitude than observations in healthy obese people may be an early marker of asthma in obese subjects with self-reported disease despite normal airflow. Increased metabolic comorbidities in these subjects may have provided a milieu that impacted airway function.

[Lung sounds can be used as an indicator for assessing severity of chronic obstructive pulmonary disease at the initial diagnosis]

OBJECTIVE

To assess the value of pulmonary auscultation for evaluating the severity of chronic obstructive pulmonary disease (COPD) at the initial diagnosis.

METHODS

The patients with newly diagnosed COPD in our hospital between May, 2016 and May, 2019 were enrolled in this study. According to the findings of pulmonary auscultation, the lung sounds were classified into 5 groups: normal breathing sounds, weakened breathing sounds, weakened breathing sounds with wheezing, obviously weakened breathing sounds, and obviously weakened breathing sounds with wheezing. The pulmonary function of the patients was graded according to GOLD guidelines, and the differential diagnosis of COPD from asthmatic asthma COPD overlap (ACO) was made based on the GOLD guidelines and the European Respiratory Criteria.

RESULTS

A total of 1046 newly diagnosed COPD patients were enrolled, including 949 male and 97 female patients with a mean age of 62.6± 8.71. According to the GOLD criteria, 88.1% of the patients were identified to have moderate or above COPD, 50.0% to have severe or above COPD; a further diagnosis of ACO was made in 347 (33.2%) of the patients. ANOVA analysis showed significant differences in disease course, FEV1, FEV1%, FEV1/FVC, FVC, FVC% and mMRC among the 5 auscultation groups (P < 0.001), but FENO did not differ significantly among them (P=0.097). The percentage of patients with wheezing in auscultation was significantly greater in ACO group than in COPD group (P < 0.001). Spearman correlation analysis showed that lung sounds was significantly correlated with disease severity, FEV1, FEV1%, FVC and FVC% of the patients (P < 0.001); Multiple linear regression analysis showed that a longer disease course, a history of smoking and lung sounds were all associated with poorer lung functions and a greater disease severity.

CONCLUSIONS

Lung sounds can be used as an indicator for assessing the severity of COPD at the initial diagnosis.

Effects of intraoperative individualized PEEP on postoperative atelectasis in obese patients: study protocol for a prospective randomized controlled trial

Background

Obese patients undergoing general anesthesia and mechanical ventilation during laparoscopic abdominal surgery commonly have a higher incidence of postoperative pulmonary complications (PPCs), due to factors such as decreasing oxygen reserve, declining functional residual capacity, and reducing lung compliance. Pulmonary atelectasis caused by pneumoperitoneum and mechanical ventilation is further aggravated in obese patients. Recent studies demonstrated that individualized positive end-expiratory pressure (iPEEP) was one of effective lung-protective ventilation strategies. However, there is still no exact method to determine the best iPEEP, especially for obese patients. Here, we will use the best static lung compliance (Cstat) method to determine iPEEP, compared with regular PEEP, by observing the atelectasis area measured by electrical impedance tomography (EIT), and try to prove a better iPEEP setting method for obese patients.

Methods

This study is a single-center, two-arm, prospective, randomized control trial. A total number of 80 obese patients with body mass index ≥ 32.5 kg/m² scheduled for laparoscopic gastric volume reduction and at medium to high risk for PPCs will be enrolled. They will be randomly assigned to control group (PEEP5 group) and iPEEP group. A PEEP of 5 cmH₂O will be used in PEEP5 group, whereas an individualized PEEP value determined by a Cstat-directed PEEP titration procedure will be applied in the iPEEP group. Standard lung-protective ventilation methods such as low tidal volumes (7 ml/kg, predicted body weight, PBW), a fraction of inspired oxygen ≥ 0.5, and recruitment maneuvers (RM) will be applied during and after operation in both groups. Primary endpoints will be postoperative atelectasis measured by chest electrical impedance tomography (EIT) and intraoperative oxygen index. Secondary endpoints will be serum IL-6, TNF-α, procalcitonin (PCT) kinetics during and after surgery, incidence of PPCs, organ dysfunction, length of in-hospital stay, and hospital expense.

Discussion

Although there are several studies about the effect of iPEEP titration on perioperative PPCs in obese patients recently, the iPEEP setting method they used was complex and was not always feasible in routine clinical practice. This trial will assess a possible simple method to determine individualized optimal PEEP in obese patients and try to demonstrate that individualized PEEP with lung-protective ventilation methods is necessary for obese patients undergoing general surgery. The results of this trial will support anesthesiologist a feasible Cstat-directed PEEP titration method during anesthesia for obese patients in attempt to prevent PPCs.

Trial registration

www.chictr.org.cn ChiCTR1900026466. Registered on 11 October 2019

High Prevalence of Obesity in Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) Requiring Invasive Mechanical Ventilation

OBJECTIVE

The COVID-19 pandemic is rapidly spreading worldwide, notably in Europe and North America where obesity is highly prevalent. The relation between obesity and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has not been fully documented.

METHODS

This retrospective cohort study analyzed the relationship between clinical characteristics, including BMI, and the requirement for invasive mechanical ventilation (IMV) in 124 consecutive patients admitted in intensive care for SARS-CoV-2 in a single French center.

RESULTS

Obesity (BMI > 30) and severe obesity (BMI > 35) were present in 47.6% and 28.2% of cases, respectively. Overall, 85 patients (68.6%) required IMV. The proportion of patients who required IMV increased with BMI categories (P < 0.01, χ² test for trend), and it was greatest in patients with BMI > 35 (85.7%). In multivariate logistic regression, the need for IMV was significantly associated with male sex (P < 0.05) and BMI (P < 0.05), independent of age, diabetes, and hypertension. The odds ratio for IMV in patients with BMI > 35 versus patients with BMI < 25 was 7.36 (1.63-33.14; P = 0.02).

CONCLUSIONS

The present study showed a high frequency of obesity among patients admitted in intensive care for SARS-CoV-2. Disease severity increased with BMI. Obesity is a risk factor for SARS-CoV-2 severity, requiring increased attention to preventive measures in susceptible individuals.

COVID-19 and diabetes: What have we learned so far?

COVID-19 and diabetes are both pandemics with major impacts on global public health. While the response to COVID-19 has been rapid and progressive to reduce risk of harm, the response to the diabetes pandemic has been somewhat more muted. People with diabetes have been disproportionately affected by COVID-19, with growing evidence of higher mortality and morbidity. In this article, we discuss the impact of COVID-19 on our diabetes service in an urban area in the UK. We discuss the impact on our patients and ourselves, and the possible lessons we can carry into the future.

Obesity and COVID-19 Severity in a Designated Hospital in Shenzhen, China

OBJECTIVE

Patients with obesity are at increased risk of exacerbations from viral respiratory infections. However, the association of obesity with the severity of coronavirus disease 2019 (COVID-19) is unclear. We examined this association using data from the only referral hospital in Shenzhen, China.

RESEARCH DESIGN AND METHODS

A total of 383 consecutively hospitalized patients with COVID-19 admitted from 11 January 2020 to 16 February 2020 and followed until 26 March 2020 at the Third People's Hospital of Shenzhen were included. Underweight was defined as a BMI <18.5 kg/m², normal weight as 18.5-23.9 kg/m², overweight as 24.0-27.9 kg/m², and obesity as ≥28 kg/m².

RESULTS

Of the 383 patients, 53.1% were normal weight, 4.2% were underweight, 32.0% were overweight, and 10.7% were obese at admission. Obese patients tended to have symptoms of cough (P = 0.03) and fever (P = 0.06) compared with patients who were not obese. Compared with normal weight patients, those who were overweight had 1.84-fold odds of developing severe COVID-19 (odds ratio [OR] 1.84, 95% CI 0.99-3.43, P = 0.05), while those who were obese were at 3.40-fold odds of developing severe disease (OR 3.40, 95% CI 1.40-2.86, P = 0.007), after adjusting for age, sex, epidemiological characteristics, days from disease onset to hospitalization, presence of hypertension, diabetes, cardiovascular disease, chronic obstructive pulmonary disease, liver disease, and cancer, and drug used for treatment. Additionally, after similar adjustment, men who were obese versus those who were normal weight were at increased odds of developing severe COVID-19 (OR 5.66, 95% CI 1.80-17.75, P = 0.003).

CONCLUSIONS

In this study, obese patients had increased odds of progressing to severe COVID-19. As the severe acute respiratory syndrome coronavirus 2 may continue to spread worldwide, clinicians should pay close attention to obese patients, who should be carefully managed with prompt and aggressive treatment.

Diabetes and COVID-19: A Review

Coronavirus Disease 2019 (COVID-19) is an emerging disease and since its first identification in Wuhan, China, in December 2019, there has been a rapid increase in cases and deaths across the world. COVID-19 has been shown to have an immense impact in infected persons with diabetes, worsening their outcome, especially in elderly, smokers, obese, those having CVD, CKD, poor glycemic control and long duration of diabetes. In this review we summarize the current understanding of `the impact of COVID-19 on diabetes and discusses the pathophysiological mechanisms and management of diabetes and its complication in this scenario.

The Lung Function Laboratory to Assist Clinical Decision-making in Pulmonology: Evolving Challenges to an Old Issue

The lung function laboratory frequently provides relevant information to the practice of pulmonology. Clinical interpretation of pulmonary function and exercise tests, however, has been complicated more recently by temporal changes in demographic characteristics (higher life expectancy), anthropometric attributes (increased obesity prevalence), and the surge of polypharmacy in a sedentary population with multiple chronic degenerative diseases. In this narrative review, we concisely discuss some key challenges to test interpretation that have been affected by these epidemiologic shifts: (a) the confounding effects of advanced age and severe obesity, (b) the contemporary controversies in the diagnosis of obstruction (including asthma and/or COPD), (c) the importance of considering the diffusing capacity of the lung for carbon monoxide (Dlco)/"accessible" alveolar volume (carbon monoxide transfer coefficient) in association with Dlco to uncover the causes of impaired gas exchange, and (d) the modern role of the pulmonary function laboratory (including cardiopulmonary exercise testing) in the investigation of undetermined dyspnea. Following a Bayesian perspective, we suggest interpretative algorithms that consider the pretest probability of abnormalities as indicated by additional clinical information. We, therefore, adopt a pragmatic approach to help the practicing pulmonologist to apply the information provided by the lung function laboratory to the care of individual patients.

Needs for Systems Approaches to Better Treat Individuals With Severe Asthma: Predicting Phenotypes and Responses to Treatments

Asthma is a frequent heterogeneous multifactorial chronic disease whose severe forms remain largely uncontrolled despite the availability of many drugs and educational therapy. Several phenotypes and endotypes of severe asthma have been described over the last two decades. Typical type-2-immunity-driven asthma remains the most frequent phenotype, and several targeted therapies have been developed and are now available. On the contrary, non-type-2 immunity-driven severe asthma is less understood and still requires efficient innovative therapies. A personalized approach would allow improving asthma control with the help of robust biomarkers able to predict phenotypes/endotypes, exacerbations, response to targeted treatments and, in the future, possible curative options. Some data from large multicenter cohorts have emerged in recent years, especially in transcriptomics. These data have to be integrated and reproduced longitudinally to provide a systems approach for asthma care. In this focused review, the needs for such an approach and the available data will be reviewed as well as the next steps for achieving personalized medicine in asthma.