Coronavirus in Context: Obesity and COVID-19: What's the Relationship?

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You're watching Coronavirus in Context. I'm Dr. John Whyte, Chief Medical Officer at WebMD. I want to spend a few minutes talking about the relationship between obesity and COVID-19. I've asked two obesity experts to join me. The first is Dr. Matthew Hutter. He's the Director of the MGH Weight Center. And Dr. Eric Demaria. He is the Chair, General and Bariatric Surgery at East Carolina University. Gentlemen, thanks for joining me.

Thank you for having us.

Thank you.

Dr. Hutter, I want to start off with you, and ask to help explain to viewers, what is the relationship between obesity and COVID-19.

Well, first and foremost, COVID-19 right now is just a terrible pandemic that's attacking all of our communities, our homes. Everyone's being personally touched by this, either physically or economically. And the future is very uncertain. And obesity is also a disease that is for many, invisible.

We can see patients with obesity, yet underlying the disease that is obesity, is invisible to most people. And so now we see, and COVID-19 is bringing this out, that obesity is actually a disease. It's not just a lifestyle choice. It's not just how people look. It's a disease. It's a metabolic disorder, and it puts people at higher risk for problems with COVID-19.

Help us understand this risk, Dr. Demaria. Is it patients who get COVID-19, are they at greater risk of mortality or a serious morbidity because of their weight? Or does being overweight and obese put you at greater risk of developing COVID-19?

People who have the disease of obesity are more likely to have a bad outcome they contract COVID-19.

Is obesity a proxy for something else? Is it really, it's about being hypertensive. It's about coronary artery disease. How do we distinguish what are the precipitating factors? Because I think there's a lot of confusion on that. Dr. Hutter, how do you tease that out?

Well, I think it's an intertwined mesh, to be honest. And obesity is a disease, and metabolic disorders are all intertwined. And so whether it's diabetes, hypertension, hypercholesterolemia, whether it's reactive, all these different aspects are part of obesity. And that's the part that people don't always see. So whether or not all those things tick up on your comorbidity scale or not, they're certainly associated, they're definitely related. And so teasing out what is obesity and what is the diabetes or the hypercholesterolemia, or the hypertension, it could be impossible sometimes.

Do we know what BMI it is that ascribes the greatest risk?

Well, we're currently learning more and more about it. And I think right now, the results are preliminary. And we're looking, and hopefully, we'll learn a lot more about this disease, coronavirus, COVID-19. And until we know, it's hard to know exactly. What we seek, are we seek early correlations. So in high volume centers, some experience in China, we do see that patients with obesity have a higher incidence of severe complications of COVID-19.

Have we've seen that in the United States, Dr. Demaria?

Yes, yes, we have. And you know, just to elaborate a little bit on what Dr. Hutter was saying, you know, it could be the obesity itself. But it really is hard to separate out the other health issues that arise from obesity. And as an example, I would say there's over 200 chronic health diseases that we know are associated with obesity. And now COVID-related complications are just another one of these health problems.

But as we try to give advice to patients, is it about letting them know it's BMI over 40? Is it being 20 pounds overweight, 10 pounds overweight, 100 pounds overweight? What guidance can we give them, if we have any, in terms of what weight it is that really starts to put them at greater risk? Because we don't want to confuse people either. So if they're five pounds overweight, that's not the same as if you have a BMI of 40 or 50 and have diabetes.

MATTHEW M. HUTTER, MD: The relationships we've seen has been with obesity, so a BMI over 30. And what we've seen in many obesity-related diseases, is that the increased level of obesity, the more exponential the rise with regards to the disease aspect goes. And I would imagine that would be a corollary with what we see with COVID-19.

Now we haven't seen that yet. I haven't seen that data currently broken out to BMI and the risk, just because the numbers and the timing where we are right now. But that's what we've seen with almost every other weight-related comorbidity. Diabetes, hypertension, hypercholesterolemia, sleep apnea. And I'm afraid the severe aspects of COVID-19 is another one of those diseases that they're more likely to get.

Let's talk about the role of bariatric surgery. As you both know, surgeries were canceled, really except for emergencies. As we're starting to reopen, it looks like orthopedic procedures are at the top. Hip replacements, knee replacements, in terms of people coming back. But so is bariatric surgery when you look at the data. Dr. Demaria, why do you think that is? And is bariatric surgery an elective procedure or is it something more serious? ERIC JOEL DEMARIA, MD: Bariatric surgery is well proven to be life saving surgery. The only thing elective about bariatric surgery is flexibility in when it is scheduled to occur. It's not elective, in that it's very much medically necessary surgery. So we're pleased that many facilities are opening back up to bariatric surgery, because there are many, many patients out there who really do need this treatment.

What are you hearing from patients that, whose schedule might have been changed because of COVID?

Well, we we're hearing all sorts of things. And I think it depends on local area that you're in, for one thing. I think there's still parts of the country where patients are a bit afraid of going in for treatment, those hot spots of COVID activity. But in many locations where the virus has not been nearly as severe, patients have been very much eager to get in and get their operations done.

You know, I've always been interested in understanding who decides if a procedure is elective or not during these times. It's not solely at the discretion of the surgeon. Is that right, Dr. Hutter?

Very true. It's a very complex issue with regards to which operations get prioritized and when. Obviously, safety should be first and foremost. But it's safety of the whole environment. It's really what the risk of communication, the ability to test, what the PPE is, N95, what the, where that stands in your specific community. How your ICU beds are, and how your anesthesia staff are doing and the nurses who take care of these patients.

Some of that is being dictated by the public health departments, correct, so the hospital and the surgeon can't simply say, I want to schedule you. I say that, because our viewers should know they still have to talk to their surgeon, and there could be other reasons why a procedure may not be able to be done.

MATTHEW M. HUTTER, MD: Absolutely. And as you said, a lot of these local issues have to be dealt with locally, depending upon the local resources, the local laws, and the local incidence of COVID in their communities. And that's the way the responsible decisions should be made.

Dr. Demaria, is bariatric surgery being resumed at your institution at East Carolina?

Yes, yes, we have restarted doing procedures. And fortunately, things are going quite well with that.

Now we did a survey on WebMD a couple weeks ago where we asked people about weight gain. And not surprising, we saw that a significant number of people reported at least a nine pound weight gain over the past few weeks. And you know, we could say, well, it's nine pounds, 10 pounds, some people were 20 pounds, some were less.

You know, it's stressful times. Dr. Hutter, it is that OK? Or do people need to be concerned about this weight gain during these stay at home orders? Because we know that longer term as we get older, people tend not to lose the weight that they gain. But what's your assessment of this weight gain?

Well, you know, I think one of the things we have to find out is, is this true? Is this true for all people? It's certainly true that stress can cause changes in how people eat and how they metabolize, the types of food that they're interested in eating. The changes in our lives. The gyms are closed. They can't physically go if you wanted to. And our routines, what's happening. But certainly the stress.

I think the stress of the uncertainty, the stress of the concern for our health, those are all major players that have been attributed to weight gain. Now what is weight gain? Well, weight gain can be very detrimental for certain people. And it's one of the things you need to consider. And so I think we're learning that that's something has to be thought about.

You're at a weight center. You were asking people a couple weeks ago, is now the time to start a diet. Is now the time to start a diet? I'll ask you. Or do you say, you know what, let's wait on that until we sort things out?

Well, I think now is the time for a healthy lifestyle. Diet is a word that people use, but I think you have to think about your relationship with food, with activity, with sleep, and you have to find the right balance that works for you. Short-term fads don't generally work, unless it's kind of an induction therapy to make those long standing changes in your lifestyle.

So I think people have to say, is this the opportunity to make some changes. And some of this may be a little bit overblown. Certainly, certain individuals are gaining a significant amount of weight. But other people are not going out to restaurants, they're eating together as a family. And I think we just have to be more thoughtful about the food choices and what we do with our time now. And it's a challenge, certainly a challenge.

I'm going to put you both on the spot. And as we talked about, obesity is a significant disease. And we know there are several factors that result in weight gain. But if I pushed you and said, you know what, nutrition versus physical activity. Which has a greater role in terms of weight gain? Is it eating food that has too many calories? Or is it being physically inactive? And I know they're both related. I'm just asking you, if you put it on the scale, which would tip more? I'm going to start with Dr. Demaria.

John, I would say it's actually an easy question, because of the studies that clearly show the diet has more to do with weight loss. And physical activity is important and useful, but in and of itself, physical activity may not even produce weight loss. But healthy living, a healthy diet is critical.

Dr. Hutter, do you agree with that?

I agree. And I think different people have different set points where their body sort of wants to be. And changing that set point, what you eat and how you eat can make a big difference in how that, in how you move that set point.

JOHN WHYTE, MD, MPH: A biologic set point.

MATTHEW M. HUTTER, MD: A biologic set point. It can change with stressors, it can change with environmental things, it can change over time. And I think that that's one of the biggest challenges that we have. But as Dr. Demaria pointed out, food is probably the biggest contributor. If you exercise and exercise and then you eat worse and worse, the food will take over.

I want to come back to that biologic set point with this premise that, are our bodies pre-programmed to be at a certain weight? So if we do different types of things, it's going to come back? Does everyone agree with that theory?

No, no, definitely not. And I think there's a nature and nurture component. There are certain biological things in our genes that may make us more likely to gain weight with certain amount of food. And there are other aspects that are environmentally or behaviorally controlled. And I think it is certainly complex.

But what we do find, is that people's body tends to defend that set point. So wherever it is or why ever it's there, once they do diet and their weight goes down, then their body says, eat more. And their metabolism slows down and their weight starts coming back up again. And so what we did, then people get a higher set point. And that up and down and up and down until the weight keeps on going up, is one of the bigger problems that we're seeing.

So now as surgeries started to be done, where can viewers find out more about weight loss surgery if that's something they want to consider?

Well, I would suggest one source is our national organization's website, the American Society for Metabolic and Bariatric Surgery. It's the asmbs.org website.

JOHN WHYTE, MD, MPH: What's the relevance of the term metabolic? That is important when we talk to patients.

I think a lot of it's change. Our understanding of obesity, that it is a disease. The American Medical Association has now identified it as a disease. And that it's not just about weight. It's not just about how you look. It's not a cosmetic thing. It's actually a disease with a disorder, and it attacks your whole metabolism.

Your metabolism with regard to diabetes, hypertension, all these obesity-related diseases, but how you fight infection. And so I think that's why COVID-19 is really, it's looking at inequalities. It's laying bare inequalities all across our country. But one of them is that patients with obesity are sicker. And this maybe is a call to say, OK, this is really one of the reasons to do something about this disease.

Absolutely. And gentlemen, I want to thank you for providing your insights today.

ERIC JOEL DEMARIA, MD: Thank you, John.

Thank you, John.

And I want to thank you for watching Coronavirus in Context. I'm Dr. John Whyte.

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