Why Obesity May Worsen COVID-19 Outcomes

John Whyte, MD, MPH; Fatima Cody Stanford, MD


April 02, 2021

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JOHN WHYTE: Welcome, everyone. I'm Dr. John Whyte, chief medical officer at WebMD. And you're watching Coronavirus in Context. We talk a lot about risk factors for obesity. And one of the biggest, no pun intended, is obesity. And we've had some conflicting data recently.

So to help dissect that data and tell us what we need to know, I've asked a good friend of mine, Dr. Fatima Cody Stanford. She is an obesity medicine physician scientist at Mass General Hospital and Harvard Medical School. Dr. Stanford, thanks for joining. It's nice to see you.

FATIMA CODY STANFORD: It is so wonderful to be here with you. This is like the delight of my week. So this is good.

JOHN WHYTE: The pleasure is mine, but thank you for saying that. I want to tease out some recent data that we've seen about obesity largely based on BMI that talks about the risk, particularly for being put on a ventilator, as well as hospitalizations and deaths. So help unpack that data for us.

FATIMA CODY STANFORD: So there are quite a few studies that have come out. I've actually published even some of these studies where what we found when we look at COVID-19 and obesity is that the way I like to say it is they don't play well in the playground together. And I'll explain why that is.

Obesity is a disease characterized by significant inflammation, but it's chronic inflammation. So it's not something that happens acutely. Obesity typically doesn't develop overnight. It's something that happens over time in both our pediatric and adult populations here in the United States and around the world.

But what we have seen is that chronic inflammation that is associated with obesity does not interact well with the acute inflammation associated with COVID-19. And what we see in that acute inflammatory process is the cytokine release, the cytokine storm. And that chronic inflammation and that acute inflammation leads to worse outcomes for patients that have this disease of obesity.

Now, you brought up a really important question that I want to really make sure that we tease out as we look at BMI or body mass index as the sole indicator for one's weight status. And what we do know is that BMI is not necessarily the best proxy for body fat.

All it tells us is height and weight, and it gives us a number. And it's based upon the Metropolitan Life Insurance tables from the 1930s. And as you can imagine in the 1930s here in the U.S. that that did not represent, for example, a diverse cohort of individuals.

There were actuarial tables. And what they used those to determine was how sick would a person become all on life insurance? And what was their likelihood of dying? And so we have to think about BMI as an imperfect measure for really looking at obviously our current issue which is COVID-19 and this chronic disease of obesity, which affects over 40% of the U.S. adult population.

JOHN WHYTE: But to be fair, does it apply to most people? Because I still see patients. And many patients will say to me, oh, they're muscular when most patients aren't because we do know that that can skew BMI. And even though it's an imperfect measure, we don't want people to think that if their BMI is elevated, particularly markedly elevated, they don't have to worry about ...

FATIMA CODY STANFORD: Oh, no. I think you're completely correct. It's not that we throw the BMI out with the bathwater. I think that's important for us to know. I think that for a population-wide measure, there are some positives in terms of trying to capture people into distinct discrete groups: those that have normal weight status, those that have overweight, and then those that have mild, moderate, or severe obesity.

But what we do know is that, for example, for the Asian population, we've redrawn the BMI scale downwards, right? So persons that have a BMI of 27-plus will have obesity. I read through the BMI charts based upon the National Health and Nutrition Examination Survey data in 2019.

And actually we saw a shift up slightly, especially for black women, where a BMI of 31 to 33 was considered to be mild obesity within that population, the population that obviously I'm a part of.

So there's some nuances. But as we look at it as a whole, as we're determining, hey, do I need a vaccine? Do I need the COVID vaccine? Where do I fall? That can help with the larger population.

Right now, we only have 10% of the population that is currently vaccinated. And we know that 40% of U.S. adults have obesity of 42.4 to be exact.

JOHN WHYTE: What about waist circumference though?

FATIMA CODY STANFORD: Oh, I love waist circumference. I actually require for every single patient in every visit that I see. And I exclusively care for patients that have a history of overweight and obesity to do waist circumference. And then, of course, our targets with waist circumference.

And I tell people, like, where do I measure? Because a lot of things are done via telehealth is to use a tape measure at their umbilicus -- their belly button. Umbilicus, you guys, is the fancy word at their belly button and what measure around that circumference. And then for men, 40 inches or less is our target. And for women, 35 inches or less. So I do couple that with the BMI data.

JOHN WHYTE: I want to go back to BMI in this recent data about increased mortality and increased risk. So we know that in terms of obesity that patients are at significantly greater risk, particularly if they're hospitalized as well.

But what about the data that shows really people that are borderline in terms of slightly overweight? And you pointed out this is imperfect measure. Their risk is actually lower. How do we account for that?

FATIMA CODY STANFORD: It's really interesting because like, that's why that data is a little bit murky. And I'm glad that you brought it up. And I want to talk about the murkiness of that data because it still is height and weight, right?

I don't know if this is fat tissue. Is this water? What is this? Like, let's say someone comes in and they have congestive heart failure. And then we diurese them. And we get 20 pounds off. And their BMI shifts 4 points. Did they really lose fat or they lost water? So it's a little bit imperfect.

But there are often in many disease processes this idea of the obesity paradox, which is once people are in this particular like, overweight category so that BMI of 25 to 29.9, that there may appear to be something that's protective.

It's hard for us to say with this current data that that is what we're really seeing. I would need to see this in a larger, like, meta-analysis, where will they consistently see that? And I would like to see it across different population cohorts, different geographic locations, for example, for really to make conclusive statements with regards to these patients that fall in that BMI of 25 to 29.9.

JOHN WHYTE: So let's put it into context for everyone for those viewers that are watching that may be overweight, may be obese, don't currently have COVID. What should they be doing today to help protect themselves?

FATIMA CODY STANFORD: Well, first, I'm going to take one word out of your vocabulary, Dr. Whyte. So I never call anyone obese. That's a word that can promote stigma and bias and makes people feel not so great about themselves. So we'll say they have the disease of obesity. So we'll use that people-first language: a person with obesity but not an obese person ...

JOHN WHYTE: Good point, similar to what we do with diabetes.

FATIMA CODY STANFORD: Yeah, with everything else, right? We don't do it with obesity, although we did change the wording at the AMA level back in 2017 to reflect this. So the key thing I think if you have obesity is to recognize that it does increase your risk for sickness, hospitalization, and death. And sometimes depending upon which study you were looking at, that value can be three to four times likelihood of hospitalization and death if you have obesity particularly.

What that means is that you likely need treatment for your disease of obesity. And thankfully, we have over 4,000 physicians now in the United States that are obesity medicine physicians that are set to care and help you care for your chronic disease of obesity.

Indeed, at the Mass General Hospital Weight Center, we've seen a tremendous increase to over 700 patients waiting to be seen for treatment for their obesity. And this appears to be associated with an interest regarding COVID-19.

So we're here. We want to help. And we can help treat this chronic disease of obesity just like we treat other chronic diseases. So I think that's the key point.

JOHN WHYTE: And it speaks to the important of vaccination. I want to ask you, 29 states have said obesity. And I'm going to use that term here because that's what they list on their website as a comorbidity -- only 29 states, so more than half. When I tell you it's 29 states, and you know some people have argued that's unfair, what do you say?

FATIMA CODY STANFORD: I say it's not. We argue it because a lot of people still have yet to recognize obesity for the disease that it is. It's an actual disease process with true pathophysiology. We know that the hypothalamus is controlling our weight and weight regulation -- how much we're eating, how much we're storing.

And when we think of obesity as an unfair advantage, then, should we think about that same issue with patients that have cancer or diabetes or other chronic disease? I think that we have to be ensuring that we have equity as it relates to these disease processes.

Obesity is a serious chronic disease and illness. It's the most prevalent in the United States. And so don't think about it as a label, like, oh, I have this disease, because the difference in obesity and these other disease process is that there's a phenotypic expression, right?

You actually see someone if they have obesity. And we make these judgments about them and their worth and their value based upon their size. And we assume they're doing X, Y, or Z without really significant knowledge about how their brain is defending their set point for weight.

So going back to the beginning and answering your question and just really supporting my answer, we need to treat obesity like any other chronic disease. And if patients have this as a disease process and they meet qualifications for vaccination, I say go. I say go get the vaccine today.

And it was literally just yesterday that a family member of mine that has severe obesity approached me via text and asked me, should she get the vaccine? And I said yes, particularly because you have severe obesity, I would be first in line because we know that people are dying at a much quicker rate if they have obesity and especially severe obesity.

And this morning, I'm glad to report she texted me her I am vaccinated. So she did listen. Your family doesn't always listen, but I was very pleased to hear her make that change.

JOHN WHYTE: You and I have known each other for a long time. We worked together a while back. We won't say the number of years. I know your journey into medicine, and I'm so happy to see your success. What has been your journey into medicine?

FATIMA CODY STANFORD: Oh, well, I decided very early in life that I wanted to be a physician. And by very early, I mean the age of 3. So I think we can all concur that that was an early decision for myself.

And, of course, the pathway has not been necessarily an easy one. It's been circuitous at times filled with challenges, hurdles, burdens. But I can say that it has been well worth it. Even ending up in obesity medicine was not something that I could have predicted. Obviously, at the age of 3, this is a very new field of medicine.

But I feel very at peace with where I am in terms of where, like the type of medicine that I practice and the type of empowerment I'm able to give, particularly to communities of color that have disproportionately higher levels of obesity.

So as I am working on and completing my fifth degree on May 11 of this year and having done two residencies, two fellowships, there have been a lot of different things that I've done along the pathway to where I am.

JOHN WHYTE: Was it more difficult for you as a woman of color?

FATIMA CODY STANFORD: From anyone that's ever seen me give a lecture about this, I talk about some of the negative experiences that I've had during my journey. And unfortunately, this is the lay of the land for persons of color, particularly women of color and particularly black women because of going back to -- we talk about those biases that people have against people that have excess weight.

There are a lot of biases. And then we know the most common form of bias in the United States is race bias followed closely by weight bias. So race, then weight.

So there are definitely challenges that I face, hurdles that I have to overcome that I think are often new hurdles when I'm talking to people that may be my mentors or people that are in a supervisory capacity that have not had to work with a black woman who happens to be a physician and scientist. And they're learning. And I'm having to mentor up, as they're navigating for the first time often having someone in their ranks that looks like me.

So it's a challenging journey but one that is very rewarding. And I spend a lot of time mentoring a lot of medical students, residents, fellows, and junior faculty, as they make their journey. And my goal, Dr. Whyte, is that they have it better than I did.

I wish I had me on me coming through to help protect me against some of the things that I faced. But if I can make it better for those coming behind me, then I've done my job.

JOHN WHYTE: And some viewers may recognize you from a few years ago when you came on the national scene for something unrelated to your obesity research. But you were on a plane, offered to give aid to a passenger. And you were questioned that are you really a doctor? And people wanted some type of verification.

FATIMA CODY STANFORD: Yeah, it's interesting. I always carry my medical license on me. I mean, in COVID, I'm mostly at home. So I don't really have to go anywhere to prove to anyone that I am a physician.

But in many instances, that was one that got a national attention. But in many instances, people don't believe that I am a physician that that can't be the case. I remember --

JOHN WHYTE: Because there's the color of your skin, right? Let's just put it out there.

FATIMA CODY STANFORD: I was -- because of the color of my skin. I'm hoping that during my lifetime, we see a change, that we see a shift. I think the shift has been minor. It in the aftermath of [George] Floyd in his murder.

But my concern is about the sustainability of valuing the black physicians that are in the workforce, whether they will be in academia, whether they be in private practice, or wherever their actual setting is.

JOHN WHYTE: Well, Dr. Stanford, I want to thank you for sharing your story today. I want to thank you for helping us unpack the data about the relationship of weight in BMI to risk of COVID as well as all you're doing in terms of mentorship and improving the profession. It's a real delight to speak with you today.

FATIMA CODY STANFORD: Oh, it's my absolute pleasure. Any time you'd like for me to come back, I will be here. Anything for you, John, any day.

JOHN WHYTE: You've got it. And if you have questions about COVID, drop us a line. You can email me at drjohn@webmd.net or post on any of our social media properties. Thanks for watching.

This interview originally appeared on WebMD on April 02, 2021

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