Since the beginning of the COVID-19 pandemic, there has been increasing evidence of the link between obesity and COVID-19 complications. The World Obesity Federation recently published a policy dossier on this topic (1). Here we discuss some of the considerations for obesity in COVID-19 responses and how steps to address obesity now can help to ‘build back better’ in the short and long term. 

Obesity and risk of COVID-19 complications

Advanced age, diabetes and CVD were identified early on in the COVID-19 pandemic as important risk factors. However, as we learn more we can now see that obesity also poses one of the highest individual risks for COVID-19 complications. Studies from a number of countries have shown that people with obesity have a higher risk of hospital admission (2, 3), admittance to intensive care (2), and need for invasive mechanical ventilation (4). The risk is particularly notable amongst Asian populations. While the highest risk of poor outcomes of COVID-19 is in older groups, a BMI >40 also appears to contribute to a higher mortality in patients under 50 (5). 

These links are of particular concern with nearly 1 billion people worldwide affected by obesity and all countries off track to meet WHO targets (6). The highest numbers and most rapid rises are seen in low- and middle- income countries, which are also particularly vulnerable to the impacts of COVID-19. 

Building resilience in the short and long term

This pandemic has brought to the fore some of the risks and challenges that result from inaction on obesity and which are faced by people living with obesity.

As with other NCDs, we have seen a direct impact of COVID-19 on people living with obesity, as a result of curtailed access to services. The pandemic has also compounded existing issues with obesity treatment, including inconsistent care pathways, stigma and lack of health coverage, as well as wider infrastructure and equipment challenges within and outside of the health system (7).

While much of the direct impact of the pandemic is on the health systems, the impact spreads much wider. Disrupted food systems (8), impacts of lockdown on behaviour and food choices, poverty, inequity, unemployment and opportunistic marketing by unhealthy commodity industries (9) are just some of the trends we see which risk increasing the double burden of malnutrition. This is particularly concerning in countries which also experience high levels of poverty and fragile health systems. In Mexico, for instance, it is estimated that the expected reduction in GDP (6%) as a result of COVID-19 could increase the number of people who are poor and food insecure by 10 million (10).

We need a long-term approach to address these issues, including prioritising obesity in global health policy, reorienting systems for better health – for example, prioritising active transport overuse of cars, ensuring equitable access to nutritious food, and health services – and implementing strong comprehensive policies that prevent obesity alongside other NCDs. 

Unless we start taking obesity seriously, populations will remain vulnerable to pandemics and other crises, and progress towards other global health targets and the SDGs will be hindered. 

What’s being done?

Some governments have responded to the links between COVID-19 and obesity with countries such as the UK, France and Mexico including people with a high BMI on their vulnerable list (1). In France, this also includes employment and salary protections.

We are yet to see a strong global response to obesity within COVID-19 responses and there is a need to strengthen responses to obesity as part of efforts to ‘build back better’. 

A group of obesity experts recently wrote an open letter to WHO’s Director-General requesting that WHO provide more COVID-19 guidance on obesity, highlighting the need to increase weight surveillance, protect people with obesity, and take steps to ensure food and nutrition security, opportunities for physical activity, and mental health support (11). The WHO COVID-19 resolution (12), while having no specific mention of obesity, presents an opportunity to integrate obesity within national COVID-19 responses through commitments on nutrition and physical activity and to protect people living with NCDs.

Act on obesity now: implement the ROOTS framework

If we are to ‘build back better’ COVID-19 responses will need to incorporate strong comprehensive policies to reduce obesity. The ROOTS framework provides the basis for action on obesity, including the need to recognise obesity as a disease, increase obesity surveillance and monitoring, address obesity throughout the life-course, equip health systems appropriately and address structural and systemic drivers of obesity (13).

We have within our grasp the means to vastly improve health outcomes but lack political will.

The link between obesity and COVID-19 complications should be seen as a stark warning of the risks of inaction on obesity, and the need to implement strong policies in order to ‘build back better' and help ensure resilient populations now and in the future.

About the authors

Simon Barquera (@sbarquera), MD, PhD, Director. Nutrition and Health Research Centre, National Institute of Public Health, Mexico (@1cinys, @INSPmx). 

Hannah Brinsden (@hannahbrins), BSc, RNutr, Director of Policy, World Obesity Federation. 

John Wilding, DM,FRCP, President-elect World Obesity Federation, Professor of Medicine & Honorary Consultant Physician, Department of Cardiovascular and Metabolic Medicine, University of Liverpool, @worldobesity. 

References

(1) World Obesity Federations COVID-19 policy dossier. Available at: https://www.worldobesity.org/resources/policy-dossiers/obesity-covid-19

(2) Petrilli, C.M. et al (2020) Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study. BMJ 2020;369:m1966

(3) Denova E., Barquera, S. Personal communication. Jun 2020

(4) Simonet et al (2020) High Prevalence of Obesity in Severe Acute Respiratory Syndrome Coronavirus‐2 (SARS‐CoV‐2) Requiring Invasive Mechanical Ventilation, 28(7), 1195-1199

(5) Klang, E. et al (2020) Morbid Obesity as an Independent Risk Factor for COVID‐19 Mortality in Hospitalized Patients Younger than 50. Obesity (early view)

(6) World Obesity Federation (2020) Obesity: Missing the 2025 Targets. Available at: https://www.worldobesity.org/resources/resource-library/world-obesity-day-missing-the-targets-report

(7) Jackson Leach, R. et al (2020). Clinical care for obesity: A preliminary survey of sixty‐eight countries. Clinical obesity, 10(2), e12357.

(8) UN Standing Committee on Nutrition (2020). The COVID-19 pandemic is disrupting people’s food environments: a resource list on Food Systems and Nutrition responses Available at: https://www.unscn.org/en/news-events/recent-news?idnews=2039

(9) NCDA. Help =map unhealthy commodity industries' responses to COVID-19. https://ncdalliance.org/news-events/news/help-map-unhealthy-commodity-industries-responses-to-covid-19

(10) CONEVAL. [Social policy in the context of the SARS-CoV-2 (COVID-19) pandemic in Mexico]. Consejo Nacional de Evaluación de la Política de Desarrollo Social: Mexico City, 2020

(11) Obesity experts write an open letter to WHO regarding COVID-19 and obesity. 

(12) COVID-19 response resolution. A73/CONF./1 Rev.1. 18 May 2020 Available at: https://apps.who.int/gb/ebwha/pdf_files/WHA73/A73_CONF1Rev1-en.pdf

(13) ROOTS declaration on obesity. Available at: https://www.worldobesityday.org/get-involved/declaration-for-world-obesity-day