Obesity in the Context of the Pandemic Caused by COVID-19

ILIE Maria-Alexandra1, MITITELU Magdalena1*, NEACȘU Sorinel Marius1, HÎNCU Lucian2

1Clinical Laboratory and Food Safety Department, Faculty of Pharmacy, ”Carol Davila” University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956, Bucharest (ROMANIA)

2Pharmaceutical Industry, Faculty of Pharmacy, ”Carol Davila” University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956, Bucharest (ROMANIA)

*corresponding author: magdamititelu@yahoo.com 


     Increased calorie intake and lack of physical activity will lead to unhealthy weight gain. Obesity and overweight are responsible for many complications, including cardiovascular disease, type 2 diabetes, liver steatosis and kidney disease. An important aspect regarding overweight or obese patients is represented by the psychological and social factors that accompany this disease. Discrimination, low self-esteem and depression are just some of the psychological and social factors that affect the lives of overweight and obese patients, both personally and professionally and socially.

Keywords: obesity, overweight, comorbidity, COVID-19


     The fact that obesity has become worrisome in recent years is no longer just a myth. Globally, statistics show that the prevalence of obesity tripled between 1975 and 2016. Thus, in 2016, 1.9 billion cases of overweight were recorded in adults over the age of 18, which means more than 39 % of the global population. Of these, over 650 million were obese, that is, a percentage higher than 13% of the entire population [1, 2].

     Although these figures indicate obesity as a major problem among the adult population, the main problem is the growing percentages since childhood. Globally, in 2016, over 41 million cases of overweight pre-schoolers were registered (Fig.1) [2]. While these figures and complications are not worrying enough, the WHO has compiled a statistic that has led to more than 2.8 million deaths annually due to overweight and obesity [1,2]. Currently, obesity is known as a chronic, non-communicable disease. It is very important to point out that obesity is a disease and not just a result of harmful habits [3].

     In the context of the pandemic caused by COVID-19, the restrictive measures taken at the level of many affected states have led to the limitation of the possibility of population movement and to the appearance of an imbalance between the caloric intake and the energy consumption of the organism. The increase of sedentary lifestyle, the amplification of the panic states during the pandemic led to the weight gain of many people in quarantine and to the aggravation of the health condition of the overweight population. Moreover, according to clinical reports, overweight and obese patients were in the high risk group in terms of the severity of COVID-19 virus infections. Furthermore, persons with obesity who become ill and require intensive care present challenges in patient management as it is more difficult to intubate patients with obesity, it can be more challenging to obtain diagnostic imaging (as there are weight limits on imaging machines), patients are more difficult to position and transport by nursing staff. In the UK, a report suggests that two thirds of people who have fallen seriously ill with coronavirus were overweight or had obesity [4]. Meanwhile, a report from Italy suggests 99% of deaths have been in patients with pre-existing conditions, including those which are commonly seen in people with obesity such as hypertension, cancer, diabetes and heart diseases [5].  

Fig. 1. Proportion of overweight and obese men (blue) and women (orange) over the age of 18 in 2016 (Source: Eurostat and World Health Organization; https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight)

Risk factors

      The causes of obesity are multiple, which is why a single treatment regimen is not sufficient or effective for all patients. Risk factors for overweight and obesity fall into four categories, namely behavioral, genetic, social and environmental factors [3,6].

       The main cause of overweight and obesity is the excessive caloric intake, along with lack of exercise and physical activity. Energy is measured in kilojoules and calories. An increased intake of calories is found in foods high in sugar, carbohydrates or fats, namely trans fats, but also in those that contain poor quality macronutrients [7,8].  It has been shown that lack of sleep can be one of the components that could lead to weight gain by producing an energy imbalance [6,9]. Quitting smoking can be a cause of weight gain [10]. All the factors presented above fall into the class of factors related to patient behaviour [11].

      Genetic factors play a very important role in weight gain. These together with the imbalance between the intake of calories ingested and those consumed are an association that could cause obesity and other complications, since childhood [12,13]. In very few cases, a clear pattern of obesity, inherited within the family, is caused by a single gene (monogenic obesity). An example of this is mutations in a gene at the melanocortin-4 receptor. A clinical study conducted in 2019 showed that mutations in a gene at this receptor are responsible for obesity. At the same time, in most situations, obesity is caused by a complex interaction between several genes and environmental factors. Unfortunately, the mechanism of obesity and its various causes are not fully known and understood [13,14].

      In addition, there are medical causes of obesity, such as hypothyroidism, Cushing’s syndrome, polycystic ovary syndrome, hyperprolactinemia, growth hormone deficiency and hypothalamic obesity, but by treating them correctly, the negative effects on weight gain can be limited [3]. Adenovirus-36 is also responsible for an energy imbalance with possible weight gain [15].

      Some medicines may be responsible for weight gain, which is why it is important to strike a risk-benefit balance before taking them. Among the drugs that cause weight gain are steroids and some antidepressants [2,16]. In addition to the factors presented above, there are a number of aspects that directly influence weight gain until the onset of obesity, namely sex and age. According to statistics, women have a higher predisposition than men for obesity. In terms of age, both men and women have a maximum onset of obesity between 40 and 60 years [3,16].

      Clinical studies also show that, in the case of men and women, there is an increase in weight starting with middle age, but also after that, for two reasons. In men, the main reason for weight gain after middle age is muscle loss. In the case of women, it is the onset of menopause, which causes a predominant distribution of body fat in the abdomen, even if there are no such large variations in weight gain [2,3,16]. Obesity since childhood is a risk factor for obesity in adults. Childhood obesity has the same causes and the same risk factors as adult obesity, which is why it is very important to educate and adopt a lifestyle that does not endanger our health [2,16]. There was a higher weight gain among children who did not receive a proper education or grew up in a low-income environment [16,17]. Social factors play an important role in the patient’s life, as they can be determinants in the appearance of obesity. One study shows that men and women who do not pursue higher education (college) are more prone to weight gain. Social factors, in turn, depend on ethnicity and race [3,16].

      Environmental factors that influence overweight and obesity take into account the constantly evolving economic field and technology. Increased productivity of workers in the advanced economy means spending more time in sedentary work and less in manual labor, so less time spent in leisure. Another example is the rich population who have an increased tendency to buy excessive items, such as televisions, cars, processed food, which has a direct link with weight gain since childhood [16]. Other factors also contribute to weight gain, such as the constant change of the work environment, but also the habits established within the family. Wrong habits, such as eating in front of the TV or computer, can be a factor in obesity. The multiple advertisements that are broadcast on television or through social networks urge the consumption of foods unsuitable for the body’s health [16].

      One factor that plays an important role in the emergence of overweight and obesity is education and the power of example. People whose knowledge of nutrition is deficient will have an increased predisposition to obesity, because they will not know the basic principles of a healthy lifestyle and will not take into account the increased calorie intake. In terms of the power of example and education, a child whose parents are overweight or obese has a higher tendency to become obese compared to a child with normal-weight parents [3,11,16].

      The most accurate tests for determining body fat are underwater body weight, CT (computed tomography), MRI (nuclear magnetic resonance) and double-energy X-ray absorptiometry. CT and MRI are used to determine and monitor abdominal fat, which is considered one of the most harmful forms and causes complications. Unfortunately, these tests are not practical for daily use in clinics and hospitals, because they are very expensive, which is why 2 parameters are used to determine body fat. These parameters are represented by BMI (body mass index), which represents the ratio between body weight (measured in kilograms) and height (measured in m²) and waist circumference [2,3,11].

Complications of obesity

      It is well known that obesity is a pathology that causes many complications throughout the body.

      Obesity and overweight are commonly associated with a wide range of health problems, such as cardiovascular problems, diabetes, high blood pressure, some cancers, reproductive system dysfunctions, psychological problems, stroke, non-alcoholic fatty liver disease, osteoarthritis, diseases of the gallbladder, but also lung diseases (Fig. 2) [2,3,11,16].

      Some symptoms that accompany obesity are insomnia, varicose veins, joint pain and dyspnea.

Fig. 2 Scheme of complications caused by overweight and obesity

      Other complications that can be caused by weight gain are mental illnesses, such as depression, anxiety, but also sleep apnea syndrome, respiratory problems, pain and poor quality of life [2,3,16].

      The occurrence of diabetes due to obesity is caused by insulin resistance, which prevents the use of glucose as an energy source by tissues and organs [2,3]. The main complications caused by overweight and obesity are located at the cardiovascular level. This is explained by the increase in blood pressure, total cholesterol, but also LDL-cholesterol (“bad” cholesterol) and decreased HDL-cholesterol (“good” cholesterol) [18,19]. Elevated blood pressure, high cholesterol and diabetes are risk factors for cardiovascular disease. The higher the patient’s risk factors, the greater the chance that he will suffer from heart failure. Even if the overweight or obese patient does not have any of the risk factors presented above, the possibility of cardiovascular problems is four times higher than in the case of a normal-weight person [20,21,22].

      Obesity is responsible for the occurrence of heart failure through a number of mechanisms. One of them is the increase in volume due to the increase in body fat, which leads to an increase in the heart’s effort to pump excess fluid. Over the years, this can lead to harmful structural and functional changes, which eventually lead to heart failure [23-27]. Fatty tissue, especially the abdominal tissue, produces a number of substances called adipokines and cytokines. These substances are toxic and cause damage to the myocardium. Even if they do not show signs of a heart condition, obese people can have chronic damage to the myocardium (heart muscle). This fact was demonstrated following a study on normal and obese patients, but who do not show symptoms characteristic of heart disease, by determining blood levels of troponin. In obese patients, troponin levels are elevated, being a silent indicator of heart damage. Elevated levels of troponin in combination with obesity present a nine-fold increased risk of heart failure for the patient over ten years [11,23,28,29,30]. Obesity is characterized by increased levels of free fatty acids and triglycerides in serum. This leads to the accumulation of lipids in tissues, such as the liver, skeletal muscle, heart and pancreatic β cells, which are severely affected. Accumulation of intracellular lipids can lead to hepatic steatosis, the installation of insulin resistance in skeletal muscle and the alteration of pancreatic β cells. In cardiomyocytes, the accumulation of lipids causes cellular alterations and ventricular dysfunction. In the case of skeletal muscle, excess free fatty acids reduce the substrate for the insulin receptor with the emergence of resistance at this level [23].


      American guidelines refer to waist circumference as a determining factor in the growth of comorbidities, such as diabetes and cardiovascular disease, in association with the patient’s sex. In men, a waist circumference greater than 104 cm (40 inches) and in women a waist circumference greater than 88 cm (35 inches) are a risk factor for comorbidities [3,23].

       In addition to age, the standard limits of waist circumference are also set according to ethnicity and race. Along with weight gain, the distribution of fat mainly in the abdomen (central adiposity) compared to that distributed in the hips and lower extremities is associated with type 2 diabetes, high blood pressure and cardiovascular disease in both men and women. A patient with fat distributed mainly in the abdomen has an increased risk of complications (diabetes, hypertension), even if he does not fall, according to BMI, obesity. In addition to central adiposity, an important role in the occurrence of complications is played by ethnicity and race. For example, the Asian population has a higher risk of developing comorbidities in the case of central obesity than in the case of high BMI values [3,23].


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