Intended for healthcare professionals

Rapid response to:


Preventing a covid-19 pandemic

BMJ 2020; 368 doi: (Published 28 February 2020) Cite this as: BMJ 2020;368:m810

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Rapid Response:

The confluence of the COVID19 pandemic with the obesity epidemic

Dear Editor,

The current Coronavirus (COVID-19/SARS-CoV-2) pandemic has been declared a Public Health Emergency of International Concern by the World Health Organisation[1]. The same organisation describes the concurrent overweight and obesity epidemic as “one of today’s most blatantly visible – yet most neglected – public health problems”[2]. What would the outcome be when these two problems intersect? We perhaps have caught a glimpse of it from the on-the-ground experience in Italy: there, obesity has been highlighted as one of the most common comorbid conditions for those patients requiring ICU admission[3].

Much is still unknown about COVID-19 and much knowledge is still to be discovered about the risk factors for the severity of illness it causes. This is seen in the speculation over the role of hypertension, diabetes mellitus and angiotension-2-increasing drugs[4]. We too wish to speculate: in our case that obesity may play a role in predicting the outcome of severity of the disease. This speculation is in keeping with retrospective analysis of obesity as a risk factor for severity of illness in other respiratory viruses including influenza[5] and MERS-CoV[6].

The exact causative mechanism for greater COVID-19 severity in obesity might be in keeping with the hypothesis raised by Fang, et al.[4], or an immunometabolic disorder such as metaflammation[7]. Interestingly, a link between Angiotensin 2 receptors and adipose tissue is proposed by Jia, et al[8]. From a practical perspective, we know that obesity is also associated with difficult intubation and difficult ventilation[9] and these may further contribute to greater disease severity and to poorer outcomes. We therefore call for formal studies analysing the relationship between disease severity and body mass index or waist to height ratios[10] of patients infected with COVID-19. We do so in the hope that we might better risk stratify patient populations to assist in both disease prevention and treatment strategies.

1. World Health Organisation. Rolling updates on coronavirus disease (COVID-19). [cited 2020 19 Mar]; Available from:
2. World Health Organisation. Controlling the global obesity epidemic. [cited 2020 19 Mar]; Available from:
3. GiViTi COVID19 Meeting 10.3.2020 - Intensive Care Patients. 2020 [cited 2020 19 Mar]; Available from:
4. Fang, L., G. Karakiulakis, and M. Roth, Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? The Lancet Respiratory Medicine, 2020.
5. Moser, J.A.S., et al., Underweight, overweight, and obesity as independent risk factors for hospitalization in adults and children from influenza and other respiratory viruses. Influenza and other respiratory viruses, 2019. 13(1): p. 3-9.
6. Badawi, A. and S.G. Ryoo, Prevalence of comorbidities in the Middle East respiratory syndrome coronavirus (MERS-CoV): a systematic review and meta-analysis. International Journal of Infectious Diseases, 2016. 49: p. 129-133.
7. Hotamisligil, G.S., Inflammation, metaflammation and immunometabolic disorders. Nature, 2017. 542: p. 177.
8. Jia, X., et al., Two Things about COVID-19 Might Need Attention. Preprints, 2020. 2020(2020020315).
9. De Jong, A., et al., How can I manage anaesthesia in obese patients? Anaesthesia, critical care & pain medicine, 2020.
10. Ashwell, M. and S. Gibson, Waist-to-height ratio as an indicator of 'early health risk': simpler and more predictive than using a 'matrix' based on BMI and waist circumference. BMJ Open, 2016. 6(3): p. e010159.

Competing interests: No competing interests

19 March 2020
Andrew Y Huang
Anaesthetist and Specialist Pain Medicine Physician
Brian Chen (Joondalup Health Campus, Perth WA)
Dept of Anaesthesia, Austin Health | Ambulatory Care Service, Eastern Health | Department of Medical Education, The University of Melbourne
Dept of Anaesthesia, Austin Health, Studley Rd, Heidelberg, Australia 3084