Impact of obesity on intensive care outcomes in patients with COVID-19 in Sweden—A cohort study

Abstract

Background Previous studies have shown that a high body mass index (BMI) is a risk factor for severe COVID-19. The aim of the present study was to assess whether a high BMI affects the risk of death or prolonged length of stay (LOS) in patients with COVID-19 during intensive care in Sweden. Methods and findings In this observational, register-based study, we included patients with COVID-19 from the Swedish Intensive Care Registry admitted to intensive care units (ICUs) in Sweden. Outcomes assessed were death during intensive care and ICU LOS ≥14 days. We used logistic regression models to evaluate the association (odds ratio [OR] and 95% confidence interval [CI]) between BMI and the outcomes. Valid weight and height information could be retrieved in 1,649 patients (1,227 (74.4%) males) with COVID-19. We found a significant association between BMI and the risk of the composite outcome death or LOS ≥14 days in survivors (OR per standard deviation [SD] increase 1.30, 95%CI 1.16–1.44, adjusted for sex, age and comorbidities), and this association remained after further adjustment for severity of illness (simplified acute physiology score; SAPS3) at ICU admission (OR 1.30 per SD, 95%CI 1.17–1.45). Individuals with a BMI ≥ 35 kg/m2 had a doubled risk of the composite outcome. A high BMI was also associated with death during intensive care and a prolonged LOS in survivors assessed as separate outcomes. The main limitations were the restriction to the first wave of the pandemic, and the lack of information on socioeconomic status as well as smoking. Conclusions In this large cohort of Swedish ICU patients with COVID-19, a high BMI was associated with increasing risk of death and prolonged length of stay in the ICU. Based on our findings, we suggest that individuals with obesity should be more closely monitored when hospitalized for COVID-19.

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“…Although collectively these parameters are consistent with those reported in other studies 17 , 23 , 32 , intriguingly, we observed that overweight/obese patients (BMI≥25) experienced less often infection requiring hospitalization compared to patients with BMI<25. In other series, obesity has been associated with worse outcomes from COVID-19, in the general population 49 , 50 , 51 and cancer 17 , whereas this correlation was not confirmed by others 52 . Overweight status has been associated with better survival in patients with advanced cancer 53 , 54 , 55 .…”

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“…Also, symptomatic breathlessness and reduced lung function among patients with obesity is more prevalent in women 32 . In contrast, men are at a significantly higher risk of developing severe COVID-19, and thus constitute a numerically dominating part of the patients in IC units 17 . However, for influenza, although men are more susceptible to infection, women have more pronounced immune responses once infected, and animal experiments also support a greater inflammatory response, impaired lung tissue repair, and hormonal triggers of pulmonary inflammation in the female sex 33 .…”

“…Additionally, overweight and obesity are known to be associated with more severe disease, in particular need of IC, while findings with respect to mortality have been more heterogeneous 5 – 11 . A recent Swedish study based on over 1600 patients treated in IC units, out of which 39% were obese, found elevated BMI to be associated with higher mortality risk 17 . However, patients admitted to dedicated IC units in Sweden are generally undergoing careful evaluation of their prospective likelihood of a favourable outcome and benefit of therapies prior to admission, and are on average younger than other hospitalised patients.…”

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“…Obese patients in particular are at increased risk of SARS-CoV-2 infection with a severe course [ 129 ]. This is particularly evident in ICU patients with COVID-19 [ 130 ].…”