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Obesity in a time of the coronavirus

Evidence suggests that obesity causes more severe Covid-19 symptoms. David Lynch looks at the impact the pandemic will have on present and future obesity treatment and policy

Even before Covid-19, obesity was increasingly regarded as one of Ireland’s most significant health challenges. But the onset of the pandemic has already impacted care for people with obesity and overall policy.

People living with obesity are named by the HSE as among the ‘high-risk groups’ in respect of Covid-19.

“Obesity does not lead to greater risk of contracting Covid-19, but the evidence suggests that people with obesity are at risk of developing severe symptoms from Covid-19,” a HSE spokesperson told the Medical Independent (MI).

The HSE has also recently published the HSE Obesity and Covid-19: National Obesity Management Clinical Programme.

This document was written by Prof Donal O’Shea, HSE Clinical Lead, and Ms Karen Gaynor, Programme Manager for the National Obesity Management Clinical Programme.

It chronicles growing clinical evidence from Italy, US, UK and China that “obesity may be linked with Covid-19 disease severity”.

Prof Donal O’Shea

According to the document, “this is important to consider, given the prevalence of obesity in Ireland,” which is 23 per cent of adults overall, 34 per cent of those aged 65-to-75, and 28 per cent of those aged over 75.

“Experience from Italian anaesthesiologists is that obesity is the most frequent comorbidity in critical care,” states the document.

The HSE also notes on its website that “a high number of people with obesity have been admitted to intensive care units (ICUs) with coronavirus”.

However, in response to what it calls “misleading reports”, the website outlines that there is no evidence that people with obesity “carry coronavirus without any symptoms for longer than other people, [or] have a higher risk of passing coronavirus on to others”.

In September 2016, the Department of Health launched A Healthy Weight for Ireland: Obesity Policy and Action Plan 2016-2025. Since then, a series of initiatives have commenced to address obesity within the public health sphere.

However, the plan did not factor-in the ramifications of a global pandemic.

What impact on obesity policy can we expect Covid-19 to have?

Future

“Well, I hope that the impact of Covid-19 will highlight obesity as a disease in its own right, a disease that needs to be prevented and treated,” said Prof O’Shea, Consultant Endocrinologist and Physician in St Vincent’s University Hospital and St Columcille’s Hospital, Dublin.

“I think there is a tendency to say, ‘well, it’s not the obesity, it’s the [other] comorbidities’. But I think it’s really kind of clear that obesity itself without any [other] comorbidities is a risk factor for landing you in ICU [with Covid-19], getting you ventilated and a bad outcome,” he told MI.

“The HSE was really beginning to prioritise obesity treatment in their thinking and I’m hoping that Covid-19 will underline the [continued] need to do that — rather than it being a reason, because of the funding crisis that we will be heading into, that they back away from prevention and treatment.

“Because that would be very short-term [planning]. If you don’t treat and prevent obesity, your costs will go up.”

Prof O’Shea does not believe the social distancing measures imposed to date will have altered the prevalence of obesity in the population. 

“I think that what would happen to population weight over an eight- or 10-week period is minimal,” Prof O’Shea said.

“If there was a slight change, when things go back to normal the population weight is likely to regress to where it was. Most of your physical activity comes not from going to the gym; it actually comes from being up and about day-to-day.

“So for me, the restricted environment in terms of the closure of McDonalds or the closure of Burger King, the fact that people are cooking more at home, eating more as a family at home; I think those restrictions are as likely to encourage positive relationships with food as they are a negative… That will be lots of families’ experience, not everybody’s, not every family’s experience, but I think in terms of impacting on weight, the impact of the restriction will really be minimal.”

Huge challenges

Last month, the Irish Society for Clinical Nutrition and Metabolism (IrSPEN) warned that patients with obesity were at higher risk of complications from Covid-19. IrSPEN said there needed to be equal access to treatments as the health system begins to address backlogs and schedule new appointments. The Society said that obesity patients must not be “stigmatised” in decisions about a restart of non-Covid health treatments.

On the future influence of Covid-19 on obesity treatment, Dr Conor Woods, Consultant Endocrinologist, Tallaght University Hospital, Dublin, told MI: “Covid-19 further highlights the need for investment in treatments for obesity.

“In those patients unfortunate to become sick with Covid-19, obesity has emerged as a risk factor for higher admission rates to hospital and for worse outcomes,” he said.

“It is therefore imperative upon us to invest in treatments to help patients with obesity address this chronic disease and reduce the risk of negative outcomes from illnesses such as Covid-19.”

But does the current crisis mean that health authorities in Ireland must look at different policies and treatments?

Dr Woods points to the importance of “weight loss surgery” (see panel below).

“Huge challenges lie before us,” he said.

“Money and resources are scarce and it is imperative on the HSE and the Department of Health to invest in treatments that yield the best outcomes for patients, reduce complications and result in cost-savings.

“One-in-four of the adult Irish population are living with obesity, so appropriate interventions to reduce obesity severity should be associated with reduced complications and risk of severe illness with subsequent waves of Covid-19.”

Inequality

In recent years, the ‘GPs at the Deep End’ group has highlighted the consequences of economic disadvantage and wealth disparity on health outcomes, including on chronic conditions. This is a trend that continues during the pandemic.

“GPs treat patients holistically and managing overweight and obesity is part of this management,” Prof Susan Smith, Professor of Primary Care Medicine, RCSI, and member of the GPs at the Deep End group, told MI.

Prof Susan Smith

“It is particularly important for conditions like type 2 diabetes. GPs practising in disadvantaged areas are already aware of the higher health needs of our patients.

“Chronic conditions develop at earlier ages and involve more complex combinations of physical and mental health problems.

“The current challenges of Covid-19 mean that many patients with chronic conditions are more socially isolated and this is likely making it more difficult to manage their chronic conditions.

“Difficulty getting out to exercise will be having a negative impact on physical health and mental health and may contribute to worsening of risk factors for poor health, like obesity.”

Regarding the current crisis, Prof Smith said “the pandemic has exposed existing health inequalities”.

“People living in the most disadvantaged communities develop multiple conditions approximately 11 years earlier than those in the most affluent communities.

“There are well-documented health inequalities and known associations between socioeconomic deprivation and poorer health indices and outcomes, including obesity in children and adults.

“Poverty results in unequal access to opportunities to make healthy lifestyle choices and unequal access to healthcare. Emerging evidence is suggesting a strong socioeconomic variation in mortality from Covid-19.

“These differences in risk likely relate to a mixture of physical and social risk factors — higher rates of chronic conditions, but also less capacity to socially isolate in households that are often overcrowded, with several generations of families living together.

“Systematic reviews have also reported a link between area-level deprivation and childhood obesity, which likely relate to difficulties accessing opportunities for exercise and health food choices due to limited household incomes.”

Isolation

The HSE Obesity and Covid-19: National Obesity Management Clinical Programme document notes that “people with obesity who are self-isolating and avoiding social contact are already stigmatised and already experiencing higher rates of depression. Social isolation is at the heart of obesity stigma.”

Is it particularly difficult for those living with obesity to deal with some of the social distancing measures?

“I think it is,” said Prof O’ Shea.

“We know that talking to the patients…that some of our patients are finding it extremely difficult. Their social supports, which may be more limited in the first place, are even more diminished. So some of our patients are finding it increasingly difficult [and] their obesity is undoubtedly playing a role in that.”

Prof O’Shea said he still does not believe there is “enough awareness” across the population around obesity.

However, he said it was encouraging to hear “more journalists, more medical people using people-first language around ‘people living with obesity’ as opposed to ‘obese people'”.

“That is encouraging, but we need more awareness; you can never have enough awareness around a condition that has been stigmatised, really now for decades, and the move away from that stigmatising to just appropriate prevention and treatment and realising that the prevention piece is very different from the treatment piece.”

According to the advice provided in HSE Obesity and Covid-19: National Obesity Management Clinical Programme, hospitals will have to plan carefully for the particular requirements of obesity patients during the present crisis.

“Special beds and positioning/transport equipment may not be widely available in hospitals,” according to the document.

“A proactive approach should be taken in managing the requirements of an increased number of individuals with obesity accessing healthcare services through risk assessment, care planning and procurement of specialist bariatric equipment.

“For example, appropriately-sized blood pressure cuffs for accurate blood pressure measurements.”

Psychological needs of obesity patients

In February, an NUI Galway study highlighted that Irish patients felt that they needed psychological services to be available as part of obesity treatment.

Dr Michelle Queally (PhD), Lecturer in the Department of Economics at NUI Galway, led the study.

Dr Michelle Queally

She told MI that the “findings in this study underscore the importance of comprehensive, integrated, evidence-based strategies that support patients in weight management”.

Despite being published before the onset of the pandemic in this country, the findings still have relevance.

“The uncertainty of the Covid-19 pandemic, the fear of becoming ill or seeing a loved one become ill, the disruption or loss of normal routines is affecting the psychological needs of all people in our society, right across the life course,” Dr Queally told MI.

“People living with the severe obesity and its related comorbidities are particularly vulnerable to the effects of Covid-19. The Covid-19 pandemic is likely to have a significant impact on the psychological needs of people with obesity.

“Severe obesity is a complex disease associated with multiple psychological and social problems, including depression and poor quality-of-life. People with obesity face many challenges in their communities, including pervasive weight bias and stigma.

“In addition, throughout the Covid-19 pandemic, we have seen an increasing frequency of ‘fat-shaming’ memes on social media, which perpetuate misconceptions about obesity and about people with obesity. People with obesity who are following Covid-19 guidelines, self-isolating and avoiding social contact are already stigmatised and already experiencing higher rates of depression.

“Stigmatising healthcare experiences may cause people with obesity to avoid or delay contacting healthcare providers during this pandemic, which may result in more severe Covid-19 outcomes.

“It is not surprising that people living with obesity might feel more anxious than normal.

“The World Obesity Federation has noted the likely impact of Covid-19 on the mental health of people living with obesity, citing the challenges faced from isolation, reduced physical activity, social engagement and employment changes.”

Dr Queally highlighted the need for meaningful consideration of the effect of the lockdown on the mental health of people living with obesity.

“Quarantine and isolation may increase psychological distress for patients with obesity in many ways, including the provision of misinformation, fear of infection, social and familial isolation, the availability of supplies, financial hardship, and stigmatisation,” she said.

“When treatment services resume, psychologists in weight management services ought to play an additional role in assessing and addressing mental health difficulties, particularly taking into consideration the impact of lockdown in severe and complex cases.

“As is already noted, it is important to have a strong connection between weight management and mental health services so that referrals between the two are seamless and that staff in both services are aware of how mental health and obesity are connected.”

Dr Queally underlined the importance of challenging the stigmatisation of people living with obesity.

“Tackling negative perceptions around people living with obesity is essential, particularly in the context of Covid-19… Weight bias and stigma have been linked to suboptimal healthcare in a variety of ways, including healthcare professionals spending less time with people with obesity; speaking less compassionately to them; misattributing symptoms to their weight instead of referring them for further testing and/or treatment options.

“Covid-19 and the negative perceptions and memes is amplifying this pre-existing disparity and needs to be addressed.”

To view the full study, visit https://bit.ly/3988kG4.

Obesity surgery a crucial treatment ‘for the individual and society’

There has been a reduction in the number of bariatric surgeries taking place in the Ireland East Hospital Group (IEHG) so far this year, according to figures provided to MI.

As with all sections of the health service, weight loss surgery has been impacted by the pandemic.

According to the HSE Clinical Lead on obesity, Prof Donal O’Shea, the impact of Covid-19 “is going to challenge the health service to maintain existing level of service, let alone prioritise and increasing [treatment in] an emerging area”.

“The problem is, the obesity surgery is an emerging area that is so far behind in Ireland compared to other developed countries, that if we let it delay further… [we could] almost enter a time warp where we are not treating obesity as the disease that it is.”

Consultant Endocrinologist at Tallaght University Hospital, Dr Conor Woods, told this newspaper that “for those affected by the negative health consequences of excess weight, such as diabetes and fatty liver disease, there are proven treatments that successfully reverse these complications”.

“Weight loss surgery restores health, reverses diabetes and fatty liver damage, prevents kidney failure and reduces the risk of certain cancers, among many other health benefits,” said Dr Woods.

“Covid-19 poses difficulties in planning and performing all elective surgery, including weight loss surgery.

“Given the medium-term and long-term benefits of weight loss surgery, every effort should be made to allow these important procedures to continue. Extra resources should be allocated to increase our capacity to perform weight loss surgery to improve health and reduce demand on acute services.

“Weight loss surgery improves quality-of-life for patients, reduces metabolic disease and generates cost-savings,” according to Dr Woods.

“Therefore, I believe a radical shift in thinking and planning is required. Weight loss surgery will take patients out of the ‘higher-risk’ groups susceptible to Covid-19 complications.

“I believe we have to ‘box clever’ and pick fights we can win. The evidence shows treatments, such as weight loss surgery, work for the individual and for society.”

Why might people with obesity be at higher risk?

▸  Obesity is linked with respiratory difficulties such as sleep apnoea, obesity hypoventilation syndrome, asthma and cardiovascular disease, which can impair oxygen levels in the blood.

▸  Obesity is associated with a significantly dysregulated immune system and impaired response to both bacterial and viral illness.

▸  Many people with obesity also have other chronic diseases, such as diabetes or high blood pressure.

▸  Obesity is linked with inflammation, which may cause a more severe inflammatory reaction in the lungs with Covid-19 infection.

Taken from Obesity and Covid-19: National Obesity Management Clinical Programme. Full document available here: https://hse.drsteevenslibrary.ie/c.php?g=679077&p=4845309

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