BCMS Medical Record Fall 2020 - 13

by Matthew Driben
BCMS Pat Sharma President's Scholarship Recipient
Advisors: Stephan R. Myers, MD, Bariatric Surgery - Tower Health Medical Group,
and Lucy J. Cairns, MD

A

fter the coronavirus SARS-CoV-2 entered the United
States in mid-January, the disease took little time to spread,
reaching the state of Pennsylvania in early March. On March
18th Berks County had its first confirmed case of COVID-19. It
did not take long for Berks to become one of Pennsylvania's most
affected counties, and as of August 2nd Berks still ranks fifth-highest
among Pennsylvania counties in number of cases per 100,000
people as well as sixth-highest in number of deaths despite being
Pennsylvania's ninth most populous county1, 2. Berks County also has
had a long history struggling with obesity and its comorbidities: a
2012 study ranked Reading in the nation's top 10 most obese cities
and estimated that its costs for obesity and other related diseases
were nearly $200 million3. Berks County's struggle with obesity has
only worsened since then-this year, Berks County has an obesity
rate of 36%, which is significantly higher than the state's obesity
rate of 30% (Figure 1)4 and the nation's obesity rate of 29%5. As
the coronavirus pandemic has evolved it has become apparent that
certain conditions, including obesity (defined as having a BMI of
30 or higher) are associated with increased rates of hospitalization,
intensive care unit use, and death from COVID-19. This article will
explore certain pathways that may explain why people of size suffer
worse COVID-19 symptoms and outcomes.

Challenges with Obesity before COVID-19
Even if they do not fall victim to COVID-19, people of size
face an increased risk of poor health. For example, obesity already
represents a state of elevated inflammation since fatty tissue produces
cytokines such as the "inflammatory triad" of TNFa, IL-1, and
IL-66. Many other inflammatory cytokines see increases as well,
including leptin, which is seen as the major hormone implicated
in obesity7. For people of size, leptin faces resistance in a similar
way to insulin in type 2 diabetes, potentially contributing to worse
outcomes in diseases such as the 2009 H1N1 pandemic6. Even
in the absence of infection, the inflammatory state induced by
excess adipose tissue results in a degree of hypoxia. Paired with
inflammation-induced ischemia, this hypoxia leads to a further
increase of cytokines and a host of chronic diseases including type 2
diabetes and cancer6.
In addition to inflammation, respiratory issues are especially
prevalent in obese patients even without COVID-19. As many as
45% of obese people have obstructive sleep apnea, which prevents
restful REM sleep6. Sleep has been well-documented as a predictor
of health, and inadequate sleep duration and sleep efficiency have
both been shown to make people more susceptible to infections
as ubiquitous as the common cold9. Obesity further damages the
immune system through other mechanisms: Extra adipose tissue
damages lymphoid organs such as bone marrow and the thymus,
which results in increased numbers of pro-inflammatory leukocytes
as well as abnormal distributions of leukocytes10. Regarding other
physical respiratory mechanisms, pulmonologist Dr. Philip Wexler
notes that excess weight on the chest cavity and diaphragm leads to
atelectasis as well as hypercapnia and hypopnea.

How COVID-19 Exacerbates Inflammation

Figure 1. Adult Obesity in Pennsylvania Counties, 20204. Berks
County has an obesity rate of 36%, which is significantly higher than the
Pennsylvania state average of 30%. Only 11 counties have higher obesity
rates than Berks.

While people of size are not at a higher risk of contracting
COVID-19, the disadvantages they already face from elevated
inflammation and pulmonary issues make them likely to suffer more
severe symptoms when they do catch COVID-19. In all cases, when
the coronavirus SARS-CoV-2 binds to the ACE2 receptor of the
cell, pathways that limit oxidative stress get blocked and pathways
that increase oxidative stress are bolstered. For some patients this
process eventually results in a "cytokine storm": an unsafe increase
in levels of the "inflammatory triad" and other similar molecules,
which are already elevated in people of size6. This cytokine storm
can explain increased coagulability as expressed by higher d-dimer
levels, which, with old age, predict higher pneumonia incidences, as
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FALL 2020

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BCMS Medical Record Fall 2020

Table of Contents for the Digital Edition of BCMS Medical Record Fall 2020

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