- By José O. Alemán-Díaz MD PhD, NYU Grossman School of Medicine

As a frontline doctor in the midst of the COVID-19 pandemic, I am witnessing the immense toll of suffering this new virus causes our patients and the US medical system. During one of my recent shifts, I admitted a middle-aged overweight black man with a new diagnosis of diabetes stemming in part from COVID-19 infection. We were worried about this patient’s course, but fortunately supported him without intensive care measures. But this case illustrates a troubling aspect of COVID-19, in the United States; it intersects with our longstanding epidemic of obesity and puts these patients, young and old, at heightened risk.

When I am not caring for COVID-19 patients I focus on hormonal diseases, specifically the twin epidemics of obesity and diabetes. Even before COVID-19, these chronic, non-infectious diseases stem from our environment’s ready access to poorly nutritious calories. Now, combined with the virus, these two epidemics threaten to bankrupt our healthcare system.

The World Health Organization (WHO) defines obesity as excess fat accumulation that causes health consequences such as type 2 diabetes. The slow-growing epidemic of obesity over the last 30 years made the population of the United States sicker than that of other developed countries, with higher rates of prediabetes, heart disease and several cancers due in part to excess weight(1). Obesity is now the leading cause of preventable disease in the United States and will soon surpass smoking as the leading preventable cause of cancer in the United States.

Early in the current pandemic physicians and scientists in China noted that COVID-19 is especially deadly in adults older than age 60. With viral spread to Italy, its medical community noticed that patients younger than age 60 with obesity and COVID-19 infection were more likely to show up at the hospital and require advanced care including needing a ventilator.

The association between obesity and COVID-19crystallized when the pandemic reached the United States, where anecdotal reports from numerous intensive care units suggested that most of their intubated patients younger than age 60 were obese. Two studies of over 3000 patients from my institution, New York University Langone Health, suggest that younger patients with obesity are more likely to be hospitalized and admitted to critical care units than their lean young counterparts (2,3). Are these observations the confluence of the epidemics of obesity and COVID-19, or is there something else?

My group and I have been investigating whether inflammation in fat occurring in obesity can be an early indicator of obesity complications such as cardiovascular disease. In the current pandemic, we hypothesize that obesity with inflammation in fat provides the soil in which COVID-19 can evoke a vigorous immune response that might prove deadly to younger patients.  This process, known as cytokine storm, is currently being targeted by anti-cytokine agents that are under investigation to prevent worsening COVID-19 respiratory symptoms.

It took the current epidemic of COVID-19 to expose the general disinterest in obesity public health over the last 30 years. We will need significant research and public health investments to understand the synergies between obesity and COVID-19, in particular those affecting underserved populations such as LatinX, African-American and rural communities. Perhaps an unintended consequence of the social isolation required to mitigate our current pandemic will be making Americans cook more and become healthier in this way (4).

In the short term, our research may add possible explanations to the association of obesity and blood sugar elevations with COVID-19 disease. Longer term, this work could add obesity with prediabetes to the list of risk factors for poor COVID-19 outcomes, and help guide treatment choice and aggressiveness for younger COVID-19 patients. Our hope is that further research into the obesity-inflammation connection may help us understand which patients with obesity benefit from additional anti-inflammatory treatments beyond losing weight, and develop new medicines that treat this chronic inflammation process.

José O. Alemán-Díaz MD Ph.D. is an Assistant Professor of Endocrinology at the New York University Grossman School of Medicine, New York University Langone Health and Attending Physician at the Manhattan Campus of the VA New York Harbor Healthcare System.

References

1. https://www.nytimes.com/2019/08/26/opinion/food-nutrition-health-care.html

2. https://academic.oup.com/cid/article/doi/10.1093/cid/ciaa415/5818333

3. https://www.medrxiv.org/content/10.1101/2020.04.08.20057794v1

4. https://www.nytimes.com/2020/04/18/opinion/covid-cooking-health.html.

We work following cohorts of patients undergoing weight loss for medical reasons to understand why some obese subjects are more or less prone to develop complications such as Type 2 Diabetes, cardiovascular disease and certain cancers. We hypothesize that obesity associated with inflammation is a risk factor in the development of these complications, and aim to develop deeper understanding of this process during weight loss. In addition, we use tools from cell biology, biochemistry, analytical chemistry and biomedical engineering to address the mechanisms behind obesity-associated inflammation.