The idea that obesity is a risk factor for contracting and having severe outcomes related to COVID-19 has been spreading since the start of the pandemic. If you were to Google the terms “obesity” and “COVID-19,” you would likely be inundated with articles about how larger-bodied people who contract COVID-19 are more likely to have severe symptoms, experience longer lasting problems, and die from the virus. Magazines, news sites, government websites, and even academics have all written about how they believe obesity is an underlying issue leading to these poor outcomes for people in larger bodies.
Academic articles and physicians have made this claim based on the limited data they had at the time of publication (1-3). Christy Harrison, respected dietician and author, asserts that these claims are severely overrated (4), but what are the risks of circulating this claim without a full understanding of how weight influences healthcare? In order to understand the damaging effects of centering obesity in the risk for COVID-19, we must first understand the impact of weight stigma in healthcare.
Weight stigma runs rampant in the U.S. healthcare system. Weight stigma is defined as negative attitudes, prejudice, and discrimination directed toward heavier individuals (5), and this type of discrimination has been found to exist in levels similar to racial or gender discrimination in our country (6). In general, weight stigma has many negative consequences for health, such as psychological and physical effects, avoidance of exercise, and disordered weight-control behaviors that can lead to clinical eating disorders (7). But in the healthcare setting, this discrimination can be even more dangerous.
Healthcare providers often have anti-fat bias, which means that they automatically associate larger-bodied individuals with negative feelings and outcomes (8). Studies have shown that many of these providers endorse negative stereotypes of “fatness,” including associating larger people with words such as “lazy,” “weak,” and “bad.” Some healthcare providers are reluctant to perform important preventative tests and exams, or even to run tests in the face of obvious and valid symptoms (8). Providers also spend less time and provide less health education to their patients that have higher BMIs (body mass index) (8). These higher-weight patients have said that they feel as though they are not welcome in medical settings and are valued less by their providers than lower-weight patients. These individuals are also three times as likely than smaller individuals to believe that they have been denied appropriate medical treatment (8). Clearly, weight stigma in healthcare can prevent heavier individuals from receiving quality or timely care (9) and can actually deter these individuals from seeking care if they have experienced weight stigma before or expect that they will be met with bias.
Christy Harrison critiques in her WIRED article (4) exactly what could be wrong about the previous findings that claim obesity is a risk factor for negative COVID-related outcomes – these studies fail to take into account the poor quality of care and other results of weight stigma that larger individuals experience. As we know that higher-weight patients often receive subpar care, it is irresponsible to ignore this factor when examining the outcomes of “obese” people.
One paper that makes this point is an analysis of 22 articles on the 2009 H1N1 influenza pandemic to see how obesity contributed to outcomes for people who contracted this serious strain of the flu (10). The authors found that there was an association between death or other serious outcomes and obesity for those that contracted the flu. However, they found that a lack of early antiviral treatment for H1N1 could be one reason for this association. Perhaps it is not obesity that made higher-weight people more vulnerable to H1N1, but the poor care they receive. While this is presented as a small finding hidden in this paper, it can show the importance of early, aggressive healthcare treatment in the face of a dangerous virus for those in larger-bodies. These results call into question our immediate association of obesity with negative consequences in medical settings. Another study, more specific to COVID-19, followed 10,131 veterans who tested positive for COVID-19 (11). Results showed that obesity was not associated with COVID-related death or hospitalization. These studies somewhat contradict earlier findings that implicate higher weight in these poor outcomes.
The perhaps overstated claims that those with obesity are at higher risk for poor COVID outcomes should be taken with a grain of salt and interpreted with a discerning eye. Such claims give the public another excuse to discriminate against higher-weight people. Medical institutions should be cautious when advertising the risks of obesity during this pandemic, as they could be doing more harm than good by perpetuating the insidious and harmful weight stigma in healthcare.
References
1. Garg S, Kim L, Whitaker M, et al. Hospitalization Rates and Characteristics of Patients Hospitalized with. Morb Mortal Wkly Report, US Dep Heal Hum Serv Dis Control Prev. 2020;69(15):458-464. https://www.cdc.gov/mmwr/volumes/69/wr/mm6915e3.htm.
2. Simonnet A, Chetboun M, Poissy J, et al. High Prevalence of Obesity in Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) Requiring Invasive Mechanical Ventilation. Obesity. 2020;28(7):1195-1199. doi:10.1002/oby.22831
3. Lighter J, Phillips M, Hochman S, et al. Obesity in Patients Younger Than 60 Years Is a Risk Factor for COVID-19 Hospital Admission. Clin Infect Dis. 2020;71(15):896-897. doi:10.1093/cid/ciaa415
4. Harrison C. Covid-19 Does Not Discriminate by Body Weight. WIRED. 2020. https://www.wired.com/story/covid-19-does-not-discriminate-by-body-weight/.
5. Tomiyama AJ. Weight stigma is stressful. A review of evidence for the cyclic Obesity/weight-based stigma model. Appetite. 2014;82:8-15. doi:10.1016/j.appet.2014.06.108
6. Puhl RM, Andreyeva T, Brownell KD. Perceptions of weight discrimination: Prevalence and comparison to race and gender discrimination in America. Int J Obes. 2008;32(6):992-1000. doi:10.1038/ijo.2008.22
7. Puhl RM, Himmelstein MS, Pearl RL. Weight stigma as a psychosocial contributor to obesity. Am Psychol. 2020;75(2):274-289. doi:10.1037/amp0000538
8. Tomiyama AJ, Carr D, Granberg EM, et al. How and why weight stigma drives the obesity “epidemic” and harms health. BMC Med. 2018;16(1):1-6. doi:10.1186/s12916-018-1116-5
9. Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev. 2015;16(4):319-326. doi:10.1111/obr.12266
10. Sun Y, Wang Q, Yang G, Lin C, Zhang Y, Yang P. Weight and prognosis for influenza A(H1N1)pdm09 infection during the pandemic period between 2009 and 2011: a systematic review of observational studies with meta-analysis. Infect Dis (Auckl). 2016;48(11-12):813-822. doi:10.1080/23744235.2016.1201721
11. Ioannou GN, Locke E, Green P, et al. Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among 10 131 US Veterans With SARS-CoV-2 Infection. JAMA Netw open. 2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310