Obesity during the COVID-19 pandemic: cause of high risk or an effect of lockdown? A population-based electronic health record analysis in 1 958 184 individuals. (preprint)

BackgroundObesity is a modifiable risk factor for coronavirus(COVID-19)-related mortality. We estimated excess mortality in obesity, both "direct", through infection, and "indirect", through changes in healthcare, and also due to potential increasing obesity during lockdown. MethodsIn population-based electronic health records for 1 958 638 individuals in England, we estimated 1-year mortality risk("direct" and "indirect" effects) for obese individuals, incorporating: (i)pre-COVID-19 risk by age, sex and comorbidities, (ii)population infection rate, and (iii)relative impact on mortality(relative risk, RR: 1.2, 1.5, 2.0 and 3.0). Using causal inference models, we estimated impact of change in body-mass index(BMI) and physical activity during 3-month lockdown on 1-year incidence for high-risk conditions(cardiovascular diseases, CVD; diabetes; chronic obstructive pulmonary disease, COPD and chronic kidney disease, CKD), accounting for confounders. FindingsFor severely obese individuals (3.5% at baseline), at 10% population infection rate, we estimated direct impact of 240 and 479 excess deaths in England at RR 1.5 and 2.0 respectively, and indirect effect of 383 to 767 excess deaths, assuming 40% and 80% will be affected at RR=1.2. Due to BMI change during the lockdown, we estimated that 97 755 (5.4%: normal weight to overweight, 5.0%: overweight to obese and 1.3%: obese to severely obese) to 434 104 individuals (15%: normal weight to overweight, 15%: overweight to obese and 6%: obese to severely obese) individuals would be at higher risk for COVID-19 over one year. InterpretationPrevention of obesity and physical activity are at least as important as physical isolation of severely obese individuals during the pandemic. O_TEXTBOXResearch in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed, medRxiv, bioRxiv, arXiv, and Wellcome Open Research for peer-reviewed articles, preprints, and research reports on obesity, excess mortality and change in body-mass index in the coronavirus disease 2019 (COVID-19), using the search terms "obesity", "coronavirus", "COVID-19", and similar terms, and "mortality", up to June 15, 2020. We found no prior studies of excess deaths in obese individuals due to COVID-19 pandemic, and no studies of long-term estimates or the relative impact of COVID-19 on mortality. Moreover, there were no studies of change in body-mass index during lockdown periods. Without these data, it is difficult to make specific recommendations in obese people at individual or population level during the pandemic. Added value of this studyWe estimated excess COVID-19-related mortality in severely obese individuals, targeted in physical distancing and isolation policies in UK government guidance. Assuming 10% infection rate, we estimated a direct impact of 240 to 479 excess deaths in England and indirect effect of 383 to 767 excess deaths. On the other hand, we estimated that between 97 755 and 434 104 individuals may develop high-risk conditions for COVID-19 mortality during a 3-month lockdown due to change in body-mass index and physical activity. Implications of all the available evidenceThese analyses support COVID-19 and non-COVID-19 impact assessment in policy planning during the pandemic. The implications of distancing and isolation measures on incidence and mortality from chronic diseases, particularly relating to obesity, needs to be considered in clinical practice, public health and research. C_TEXTBOX

Excess deaths in people with cardiovascular diseases during the COVID-19 pandemic. (preprint)

Background: Cardiovascular diseases(CVD) increase mortality risk from coronavirus infection(COVID-19), but there are concerns that the pandemic has affected supply and demand of acute cardiovascular care. We estimated excess mortality in specific CVDs, both direct, through infection, and indirect, through changes in healthcare. Methods: We used population-based electronic health records from 3,862,012 individuals in England to estimate pre- and post-COVID-19 mortality risk(direct effect) for people with incident and prevalent CVD. We incorporated: (i)pre-COVID-19 risk by age, sex and comorbidities, (ii)estimated population COVID-19 prevalence, and (iii)estimated relative impact of COVID-19 on mortality(relative risk, RR: 1.5, 2.0 and 3.0). For indirect effects, we analysed weekly mortality and emergency department data for England/Wales and monthly hospital data from England(n=2), China(n=5) and Italy(n=1) for CVD referral, diagnosis and treatment until 1 May 2020. Findings: CVD service activity decreased by 60-100% compared with pre-pandemic levels in eight hospitals across China, Italy and England during the pandemic. In China, activity remained below pre-COVID-19 levels for 2-3 months even after easing lockdown, and is still reduced in Italy and England. Mortality data suggest indirect effects on CVD will be delayed rather than contemporaneous(peak RR 1.4). For total CVD(incident and prevalent), at 10% population COVID-19 rate, we estimated direct impact of 31,205 and 62,410 excess deaths in England at RR 1.5 and 2.0 respectively, and indirect effect of 49932 to 99865 excess deaths. Interpretation: Supply and demand for CVD services have dramatically reduced across countries with potential for substantial, but avoidable, excess mortality during and after the COVID-19 pandemic.