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The COVID‐19 pandemic has caused a severe public health, social, and economic crisis. Globally, the United States has the most COVID‐19 deaths (~ 25%) representing < 5% of the world’s population. COVID‐19 severity ranges from asymptomatic to fatal, with poor cardiometabolic health a major risk factor for worse outcomes.
Study Synopsis and Perspective
The majority of COVID-19 hospitalizations in the United States are attributable to 4 preexisting cardiometabolic conditions, a new study suggests.
The authors estimated that among the 906,849 total COVID-19 hospitalizations that had occurred among US adults as of November 2020, 30% were attributable to obesity; 26% to hypertension; 21% to diabetes; and 12% to heart failure.
From the data, the investigators estimated that almost two-thirds (63.5%) of the hospitalizations were attributable to these cardiometabolic conditions and that those hospitalizations would have been preventable had those conditions not been present.
They estimated that a 10% reduction in these 4 cardiometabolic conditions would potentially have prevented 11.1% of COVID-19 hospitalizations.
The authors believe more should be done to promote healthy lifestyle measures to improve overall cardiometabolic health and potentially minimize the risk for severe COVID-19.
“It is a sad fact that this disease has been around for a whole year with millions dead and tens of millions hospitalized worldwide, and we haven’t addressed one of the major ways of preventing such severe outcomes,” senior author Dariush Mozaffarian, MD, told Medscape Medical News.
“We are closing businesses and stopping people from seeing their loved ones, but we are not telling them to lose weight and do some exercise. We should be focusing public health messages on reducing diabetes and obesity as a means to reducing severe COVID disease,” he said.
Mozaffarian, who is a cardiologist and dean of the Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy at Tufts University, Boston, Massachusetts, added: “If individuals exercised a little more and ate a bit more healthily, we would see improvements in diabetes and hypertension in just a few weeks. We should be shouting this from the rooftops, along with the messages to wash hands, social distance, and wear masks.”
The study was published in the February issue of the Journal of the American Heart Association.
For their study, the researchers employed a mathematical simulation to estimate the number and proportion of national COVID-19 hospitalizations that could have been prevented had Americans not experienced 4 major cardiometabolic conditions.
The researchers used data on the association between COVID-19 hospitalizations and each of the 4 conditions from a study of factors associated with hospital admission among 5279 patients with COVID-19 at a major health center in New York City.
Data from the Centers for Disease Control and Prevention’s COVID-NET system and from the COVID Tracking Project were used to estimate COVID-19 hospitalizations by population subgroup. The data on the national distribution of the 4 conditions came from the most recent National Health and Nutrition Examination Survey.
The model indicated that age and race/ethnicity were associated with disparities in COVID-19 hospitalizations as a result of these 4 conditions. For example, about 8% of COVID-19 hospitalizations among adults aged < 50 years were estimated to be a result of diabetes compared with about 29% of COVID-19 hospitalizations among persons aged ≥ 65 years. Obesity had an equally detrimental impact on COVID-19 hospitalizations across age groups.
At any age, COVID-19 hospitalizations attributable to all 4 conditions were higher in Black individuals than in White individuals and were generally higher with regard to diabetes and obesity among Hispanic persons than among White persons.
For example, for persons aged ≥ 65 years, diabetes was estimated to cause about 25% of COVID-19 hospitalizations among White individuals, about 32% among Black individuals, and about 34% among Hispanic persons.
When the 4 conditions were considered together, the proportion of attributable hospitalizations was highest for Black adults of all ages, followed by Hispanic adults. For example, among adults aged 18 to 49 years, the 4 conditions jointly were estimated to cause about 29% of COVID-19 hospitalizations among White persons and 34% among Black persons.
“National data show that Black and Hispanic Americans are suffering the worst outcomes from COVID-19. Our findings lend support to the need for prioritizing vaccine distribution, good nutrition, and other preventive measures to people with cardiometabolic conditions, particularly among groups most affected by health disparities,” Mozaffarian said.
“Policies aimed at reducing the prevalence of these four cardiometabolic conditions among Black and Hispanic Americans must be part of any state or national policy discussion aimed at reducing health disparities from COVID-19,” he said.
Mozaffarian pointed out that the study used an established analytic modeling approach but that the results are estimates and do not prove cause and effect.
“Association does not equal causation, and our modelling approach does not prove that improvements in cardiometabolic health will reduce the risk of COVID-19 hospitalization. However, the magnitude of our simulated findings supports the need for interventional studies to test this possibility,” the researchers state.
Still, Mozaffarian believes the results do reflect cause and effect.
“These conditions are very strongly related to severe COVID infection. We adjusted for age, sex, and other medical conditions, and we still found these four cardiometabolic conditions to be independently associated with COVID hospitalization,” he noted. “This is not just a respiratory virus. It causes widespread vascular inflammation, which is consistent with these cardiometabolic conditions. If these conditions weren’t there, COVID would be less severe,” he commented, “but even if our 64% estimate is off by half — which I don’t believe it is — that would still be one third of severe cases caused by four cardiometabolic diseases that can be prevented. These are huge numbers.”
COVID-19 is a fast pandemic on top of the slow pandemic of obesity and diabetes.
Mozaffarian stressed the need for the public to understand the importance of good nutrition.
“This is the foundation to heath. Poor nutrition is the single biggest contributor to disease globally, and it is also contributing to COVID situation,” he said. “COVID-19 is a fast pandemic on top of the slow pandemic of obesity and diabetes.”
Commenting on the study for Medscape Medical News, George L. Bakris, MD, professor of medicine and director of the American Heart Association Comprehensive Hypertension Center at the University of Chicago Medicine, Chicago, Illinois, said the data were consistent with observations that older people, especially persons with diabetes, heart disease, and pulmonary disease, are at higher risk for more severe disease manifestations of COVID-19.
He noted, however, that on the basis of many epidemiologic substudies, hypertension alone, in the absence of heart disease, lung disease, or diabetes, has not been implicated as a factor in the severity of COVID-19.
“The government has previously had campaigns encouraging exercise and weight loss, and all the programs available to help facilitate this have not helped. The concept of cognitive dissonance is applicable. While people are aware of the risks, they have great difficulty changing behavior,” Bakris added.
Acknowledging the difficulty in persuading people to change their habits, Mozaffarian pointed out that the COVID-19 pandemic is an exceptional event and has caused the vast majority of people to change their behavior.
“People would also make changes to their diet and exercise habits if they were given a clear message that this could reduce their risk of a severe COVID outcome,” he said.
He urged the major stakeholders — governments, cardiovascular societies, and businesses — to deliver that message.
“Every single day, we should be hearing advice to eat more vegetables and fewer chips, sodas, and processed foods and walk a bit more,” he said. “This could have a massive effect on COVID disease outcomes and on overall public health.”
Also commenting on the study for Medscape Medical News, 2 experts broadly agreed with conclusions reached by the authors.
“These are reasonable conclusions but with the limitations acknowledged by the authors that what is demonstrated here are associations and may or may not be causally related,” said Darren McGuire, MD, professor of internal medicine at the University of Texas Southwestern Medical Center, Dallas, Texas. “That is, modifying the risk factor may or may not modify the severity of COVID infection.
“At the very least, these observations provide strong support for the hypothesis that could be tested in randomized trials of lifestyle interventions. But it is also reasonable to consider applying such approaches anyway, given the breadth of health benefits of normal weight, absence of diabetes, and normal blood pressure,” McGuire added. “Both government and medical societies should support such efforts.”
Robert Eckel, MD, professor emeritus of medicine at the University of Colorado Denver and past president of both the American Heart Association and the American Diabetes Association, said he might take some issue with the term “attributable” in the authors’ conclusion.
“A better descriptor would be ‘associated,'” he said, but he agreed with the idea of a public health campaign urging people to eat more healthily and exercise more as a way of reducing their risk for severe COVID-19.
The research was supported by the National Institutes of Health and the National Heart, Lung, and Blood Institute. Mozaffarian has received research funding from the Gates Foundation and the Rockefeller Foundation; personal fees from the Global Organization for EPA and DHA Omega-3s (GOED); Barilla Holding S.p.A.; Bunge Limited; Indigo Ag, Inc.; Motif FoodWorks, Inc.; Amarin Corporation; the Cleveland Clinic Foundation; America’s Test Kitchen® (modest); and Acasti Pharma Inc. and Danone S.A. (significant). He has participated on scientific advisory boards of start-up companies focused on innovations for health, including Brightseed; Calibrate Health; DayTwo Inc.; Elysium Health; Filtricine, Inc.; Foodome Inc.; HumanCo; and Tiny Organics Inc. (significant) and has received chapter royalties from UpToDate, Inc. (modest), all outside the submitted work.
J Am Heart Assoc. Published online February 25, 2021.
- Researchers used best available estimates of independent associations of cardiometabolic conditions with COVID‐19 hospitalization risk and combined inputs in a comparative risk assessment framework.
- Of 906,849 COVID‐19 hospitalizations in US adults as of November 18, 2020, ~ 20.5% were attributable to diabetes, 30.2% to total obesity (BMI ≥ 30 kg/m2), 25.5% to hypertension, and 11.7% to heart failure.
- Attributable proportions were multiplicative, not additive, when ≥ 2 conditions were present.
- Considered jointly, 63.5% of COVID‐19 hospitalizations were attributable to these 4 conditions (ie, preventable absent these conditions).
- There were large differences in proportions of cardiometabolic risk-attributable COVID‐19 hospitalizations by age and race/ethnicity, and smaller differences by sex.
- Diabetes led to ~ 8% of COVID-19 hospitalizations among adults aged < 50 years vs ~ 29% among persons aged ≥ 65 years.
- Severe obesity (BMI > 40 kg/m2) increased COVID-19 hospitalizations similarly across age groups.
- At any age, COVID-19 hospitalizations attributable to all 4 conditions were higher in Black persons than in White persons; those attributed to diabetes and obesity were generally higher in Hispanic persons than in White persons.
- At age ≥ 65 years, diabetes was estimated to cause ~ 25% of COVID-19 hospitalizations among White persons, ~ 32% among Black persons, and ~ 34% among Hispanic persons.
- Pooling the 4 conditions, Black persons of all ages had the highest proportion of attributable hospitalizations, followed by Hispanic persons.
- Among adults aged 18 to 49 years, the 4 conditions jointly caused ~ 29% of COVID-19 hospitalizations among White persons and ~ 34% among Black persons.
- The investigators concluded that a substantial proportion of US COVID‐19 hospitalizations appears attributable to major cardiometabolic conditions, which may help inform public health prevention strategies to reduce COVID‐19 healthcare burdens.
- 10% reduction in these conditions could potentially prevent 11.1% of COVID‐19 hospitalizations.
- Clinicians should educate at-risk patients regarding preventive lifestyle measures, such as improved dietary quality and physical activity, to improve overall cardiometabolic health and potentially reduce COVID-19 severity risk.
- The findings support prioritizing vaccine distribution, good nutrition, and other preventive measures to people with cardiometabolic conditions, particularly among the elderly, and Black persons and Hispanic persons most affected by health disparities.
- Any strategies to lower health disparities from COVID-19 must include policies to lower US prevalence of these 4 cardiometabolic conditions.
- Study limitations include inability to prove causality of the associations, but these are biologically plausible.
- Cardiometabolic diseases are associated with decreased immunity, endothelial dysfunction, and chronic systemic inflammation, which could exacerbate cytokine storm and thrombotic complications of COVID-19.
- Obesity can lower pulmonary function and ventilatory reserve.
- Controlled trials are urgently needed to determine whether improving cardiometabolic health will reduce hospitalizations, morbidity, and healthcare burdens from COVID‐19.
- Major cardiometabolic conditions account for a substantial proportion of US COVID‐19 hospitalizations, which may help inform public health prevention strategies to reduce COVID‐19 healthcare burdens. The results also support prioritizing vaccine distribution, good nutrition, and other preventive measures to people with cardiometabolic conditions, particularly among the elderly, and Black persons and Hispanic persons most affected by health disparities.
- The findings support prioritizing vaccine distribution, good nutrition, and other preventive measures to people with cardiometabolic conditions, particularly among the elderly, and Black and Hispanic persons most affected by health disparities.
- Implications for the Health Care Team: Clinicians should educate at-risk patients regarding preventive lifestyle measures, such as improved dietary quality and physical activity, to improve overall cardiometabolic health and potentially reduce COVID-19 severity risk.
Créditos: Comité científico Covid