We are pleased to interview the Co-chairs of the EASO Obesity Management Task Force on publication of Obesity and COVID-19: The Two Sides of the Coin in Obesity Facts: the European Journal of Obesity. https://www.karger.com/Article/FullText/510005 Many thanks to Dr Dror Dicker and Dr Luca Busetto for taking time to speak with us.
This has been a very difficult several months for the EASO clinical and patient communities, and there have been significant differences in experience between countries. Professor Busetto, your home region in Italy was on the leading edge of the global pandemic. What is the situation in Lombardy like now?
I work in the Veneto Region, very close to Lombardy and we faced a very difficult situation in March and April, when the number of COVID-19 grew very rapidly. Our national and regional authorities implemented very strict rules about physical distance and lockdown and I am proud to say that our citizens very strictly adhered to them. The number of cases abated rapidly and now we have a 10-20 new cases in the region daily in this area where we have 5 millions inhabitants. Nonetheless, this means that the virus has not disappeared and we are now facing some clusters of infections, some of these are local and others are imported from abroad. Thus our COVID ward should remain alert and well staffed, and we need to be prepared for new surges of COVID-19 cases.
Dr. Dicker, after a strong initial national response in Israel to COVID-19, the resurgence of positive cases led to a reinstitution of lockdown after some return to normalcy and the re-opening of schools.
Yes indeed, we experiencing now a new wave of COVID-19 infections, with increasing numbers of new cases, mainly among young age groups. We have also seen an increase in the number of severe cases. We estimate that the early, widespread re-opening following the total lockdown is responsible for this. Due to the high number of new cases each day (1200-1600), breaking the chain of infection is very difficult. In the end, it all comes down to personal and social responsibility, and maintaining physical distancing, wearing masks and personal hygiene. The issue of obesity as a major risk factor for morbidity and mortality in this pandemic is not yet recognised and we have to work on this perception here in Israel as I imagine we must do in many places around the globe.
The paper clearly describes the biological and physiological reasons that adults living with obesity are prone to COVID-19 infection and its complications if exposed to the virus, and the fact that adults with obesity are at a higher risk for admission to intensive care units (ICUs) and intubation if infected with Sars CoV2.
In the beginning of the pandemic the papers that were published did not include obesity as a basic characteristic and the risk was not reported. Only later reports from France and USA highlight that obesity was a risk factor for ICU admission, mechanical ventilation and death. Today we recognise that obesity is the most important risk factor for death and mechanical ventilation in COVID-19 patients. In the position paper we describe the reasons that lead to these devastating results, mainly due to: baseline low grade inflammation, lower immunity, lower lung function, and the higher rate of other risk factors for CVD. These notions should lead us to prioritise treatment for people living with obesity.
Your paper also highlights the fact that COVID-19 has been a barrier to obesity treatment and care across Europe, and uses an EASO survey of the Centres for Obesity Management (COMs) to provide a clear picture exploring the challenge of providing care to people with obesity in multi-disciplinary treatment centres across Europe. Obesity clinics were closed and outpatient appointments were cancelled or postponed during the height of the pandemic. The COMs survey shows that 61% of HCPs diverted from their principal duties to provide COVID-19 care; this was particularly the case for physicians and nurses. In addition, with surgical capacity focused on COVID-19, bariatric surgery has been postponed and has not been re-prioritised by national and local health services once surgical care re-opens.
I think that the results of this survey are very relevant, because they clearly describe what happened across Europe during the past months. We know that the shift of health care resources and attention to COVID-19 care negatively affected care for many NCDs. However, our data seems to suggest that the situation is even worse for obesity management. This could be linked to the stigma affecting obesity and to the fact that most countries are still lacking clear recognition of obesity as a chronic relapsing disease, deserving the same attention and care as other, recognised NCDs, like diabetes.
With health systems facing dramatic increases in demand for traditional service provision as well as pandemic care, the reality across Europe points to the challenges posed by the continuing lack of recognition of obesity as an NCD within most European health systems, compounding present and future obstacles for national health systems and creating significant issues for vulnerable patients and HCPs.
This should be our most important policy issue for the future and I am sure that EASO will work on this issue and will support our National Associations in developing national initiatives.
The EASO paper includes an important call for action:
- Early detection and testing of COVID-19 in PwO.
- Prompt therapy for PwO affected by SARS-CoV-2 or by other viral diseases, to avoid further deterioration in health.
- Due to prolonged viral shedding, isolation of positive cases and physical distancing should be implemented immediately. This is to prevent further spreading of the disease and requires substantial planning in terms of minimising economic hardship and food insecurity.
- Once a safe vaccine becomes available, the immune response should be assessed in PwO. Specific interventions to encourage vaccination may be necessary to avoid infections and further complications in PwO.
In addition, we suggest further interventions that are aimed at improving the immune response of PwO:
- Supporting and promoting access to healthy food and dietary patterns, to reduce levels of ACE2. In mice, ACE2 is expressed in adipose tissue and is induced by a high-fat diet
- Facilitating and encouraging mild-to-moderate physical activity through COVID-19-related strategies and interventions, including tailored modification for those with barriers and physical limitations. Physical exercise has an anti-inflammatory effect and has been shown to improve the hormone milieu, increasing adiponectin and insulin sensitivity and decreasing insulin and leptin levels, and to enhance immune function
- Attention should be focused on addressing the social determinants of health associated with obesity such as poverty, low levels of education, the physical environment (e.g., overcrowded neighbourhoods where poor diet, sedentary behaviours, and obesity often coexist), marketing of non-nutritious edible products, and access to COVID-19 information and health services for vulnerable communities.
- Developing awareness and consideration of how weight bias and obesity stigma may impact COVID-19 testing, treatment, care, and health outcomes for PwO.
Finally, the following health services policy actions are recommended in order to maintain adequate obesity care during the pandemic:
- Maintain access to chronic disease care (including obesity care), as much as possible, by preventing significant reassignment of HCPs displaced to critical care.
- Assure safe pathways for the continuation of in-person consultation for PwO including provision of suitably sized and personal protective equipment and staff for patients.
- Encourage and facilitate the complementary use of virtual contacts and telemedicine in obesity care and prepare for future situations where access to in-person visits will be difficult.
- Assure an adequate number of bariatric surgery procedures and reduce waiting times while allowing for more timely pre-operative care.
The full publication is available open access from Karger Publisher online first in Obesity Facts: https://www.karger.com/Article/FullText/510005