“No need for [intensive care], just five days in hospital, quick recovery, back in full-time work and playing vigorous singles tennis within three to four weeks of discharge,” he says.
If anyone needed a reason to lose weight, the novel coronavirus provides a powerful incentive.
Obesity, a significant public health problem among both American adults and children, is one of the risk factors for severe disease and death from covid-19, the disease caused by the coronavirus. Others include older age and such underlying medical conditions as heart disease and diabetes, both of them related to obesity.
Obesity grew from 30.5 percent to 42.4 percent among American adults between 2000 and 2018, while severe obesity rose from 4.7 percent to 9.2 percent, according to the Centers for Disease Control and Prevention. Moreover, obesity contributes to heart disease, stroke and Type 2 diabetes, which increase the risk.
Researchers don’t yet know why obesity worsens covid-19. They are trying to untangle the reasons, with several ideas under study. “It’s clear that we need to think more deeply about what it is about the obese state that makes covid-19 more deadly,” O’Rahilly says.
But they agree that one way to likely reduce the risk is to do what O’Rahilly did: drop some excess pounds.
“Age remains the strongest risk factor for covid-19, also being male or having specific medical conditions, but as we cannot change age or being a male, weight may be the major modifiable risk factor for severe covid-19,” says Naveed Sattar, professor of metabolic medicine at the University of Glasgow’s Institute of Cardiovascular & Medical Sciences.
“Some countries, such as the U.K., have now started to take a stronger approach to the prevention and management of obesity,” Sattar says, with a public campaign to encourage its citizens to lose weight as a means to prevent severe covid-19 disease.
Sattar says that, among other things, being seriously overweight makes it more difficult to breathe, increasing covid’s harmful effects on the lungs.
“When people carry extra weight, this can lessen their lungs’ ability to extract oxygen from the air, and excess weight also impairs the heart and blood vessels ability to deliver this oxygen around the body, as blood vessels become stiffer and blood pressure levels go up with obesity,” he says.
Furthermore, Sattar says, obesity causes the blood to become thicker or stickier than normal, a condition made worse by the virus. This increases the possibility of blood clots. “Also, severe covid-19 reactions appear linked to the body’s immune response going into overdrive, and some speculate that this is greater in those with excess body fat,” he says.
O’Rahilly thinks that disruptions in the body’s metabolism caused by obesity may be the prime reason being overweight contributes to severe covid-19.
“Explanations around ‘heavy chests’ and upper airways narrowed by fat just don’t cut it,” he says. “We have to look closely into the metabolic effects associated with obesity. Only then will we possibly find paths to interventions that can really be protective.”
The virus enters the deep parts of the lung through ACE2 receptors, proteins attached to cells in the lung and elsewhere, which is the reason for lung inflammation and the formation of small local clots.
Most people die of covid-19 because they can’t get enough oxygen into their bodies through their lungs. This happens because the thin layer of lung cells that oxygen must pass through becomes damaged and swollen by the virus.
“This is further complicated by the fact that the blood supply to the parts of the lungs that normally take up oxygen is blocked off by tiny clots, which are a really striking feature of covid-19,” O’Rahilly says.
Obesity can influence several steps in this process, O’Rahilly adds.
“Obesity is strongly associated with a ‘sick’ metabolic state called insulin resistance,” he says, referring to a condition where the tissues that normally handle glucose in the body become less responsive to insulin, prompting the levels of insulin in the blood to climb higher to compensate. This “is often the prelude to obese people becoming diabetic,” he says.
Insulin resistance causes increases in inflammation-producing molecules, he says, and is associated with rising blood levels of the Complement component 3 protein, part of the body’s “innate” or first defense immune system, which attacks cells infected with virus. Too much C3, however, causes excessive inflammation and small clots in blood vessels.
“In fact, in covid-19, there is good evidence that Complement is involved in the damage seen to lung tissues, and its small blood vessels,” O’Rahilly says. “Obesity and insulin resistance may be ‘loading the gun,’ with too much Complement, predisposing one to greater damage when the virus comes along.”
Obesity also prompts a reduction of adiponectin, a hormone secreted by adipose tissue, which is where the body stores fat. Obese people tend to have low levels, while thin people have more. Adiponectin protects the lung blood vessel linings from inflammation, he says. Along with the formation of “stickier” platelets, which start clots, obesity also increases levels of another protein, plasminogen activator inhibitor 1 (PAI-1), that prevents clots from breaking down.
“All of the above effects of insulin resistance are well established and replicated — their impact on the worse outcome of covid-19 in the obese remains theoretical but highly likely in my view,” O’Rahilly says.
Candida Rebello, a postdoctoral researcher at the Pennington Biomedical Research Center, agrees that multiple factors are probably involved in obesity’s dangerous effect on covid-19 — citing insulin resistance, chronic inflammation of fat tissue and the effects of the pressure of excess fat around the lungs — but she speculates that leptin, an appetite-regulating hormone produced by fat cells, also may play a role.
“When fat stores are low, leptin signals to the brain to increase appetite,” she explains. “However, when fat stores increase, leptin increases. When fat stores are increased — as in obesity — a condition called leptin resistance develops where the brain does not receive a signal to lower appetite. The fat cells continue to secrete leptin in an effort to convince the brain to lower appetite, causing blood levels of leptin to rise.”
Typically, the body secretes leptin to meet its needs, she says.
“When leptin levels are out of balance, as occurs in obesity, the immune response could be ineffective, insufficient or misdirected,” she says. “Viral replication increases and its clearance reduces. Damage to tissue can precipitate a new response and a spiraling effect that can cause a lot of damage to tissues and organs.”
Research is still underway. But there’s no need to wait for it, O’Rahilly says. Begin taking in fewer calories than you are burning, even for a few days. That’s enough for insulin resistance to start to improve.
“[This] may be something that most overweight people can take on board,” he says, “even before they see much of a change on the scales or in their clothes.”