Covid Contiki Tour Part 2

Part 2 of our Covid Contiki tour is here! We're continuing our whirlwind trip around the world to see what the data tells us about the relationship between body size and COVID-19. Diet culture is busily creating a narrative that being larger is a huge risk factor for contracting, developing complications, and even dying from the virus, and our BS detectors are UP!  Alongside my fellow travel guides Jess Campbell (nutritionist and medical student) and Fiona Willer (anti-diet dietitian and statistical warrior), we're diving deep into the data to reveal the real picture - and the truth is VERY DIFFERENT from the headlines! In Part 1 we visited China and the USA, and in this episode we're off to France, Italy, and the UK. What we find will blow your mind! This is a MUST LISTEN!
CW - this episode discusses severe illness and death, and mentions the "O" word multiple times. If you're finding it all a bit much, wait until you've got some gas in the tank. But if you're ready to get totally fired up about how weight bias is impacting our understanding of this pandemic, let's go!

 

Shownotes

 

 

We’re back, and we’re heading to France! There’s a study out of France that’s again being used to push this idea of BMI being related to not just hospitalisation but seriousness of the COVID19 illness, such as the need for intensive interventions such as ventilation. It’s a small study with the title “Obesity is an independent risk factor for severe COVID 19”. So, it’s upping the ante in this article to claim that body size is an independent risk factor for severity, or how sick you get with COVID 19. The study is of 124 patients who were admitted to the ICU in a hospital in Lille, France. What the New York Times article mentioning this study said was that nearly half of the 124 patients in this study were ‘obese’ (Louise is feeling some fatigue at saying the ‘o’ word). They say that this is twice the obesity rate of a comparison group admitted to ICU for other reasons last year. It also claimed that as people's body weight went up, so did their need for ventilation. Things to look at in this paper - who were the people being admitted? 73% were male, average age 60. The study controlled for age, diabetes and hypertension, but didn’t control for other factors which have been found to be really important here - things like  smoking, cardiovascular disease, cancer, chronic respiratory disease. There’s no mention either in this paper of social disadvantage. Lille in France is a working class city with a really high poverty rate, so 1 in 4 people in Lille live below the poverty line. That fact isn’t mentioned anywhere in the paper or in the New York Times article. If you read something about body size and COVID symptom severity, you are not being told the full picture when it comes to health and what impacts on our health and our ability to fight back and recover from an infection which we have no immunity for. Next stop, Italy! Italy has been hit so incredibly hard by COVID, we’re seeing a huge impact there and some horrible statistics on death rates. They’ve managed to get some data together and put out some papers, which is an amazing effort. A paper released recently on the 20th of April 2020 looks at outcomes (deaths) and is pretty heavy-going. It’s a large study, including 21,500 people who died. It digs into the relationship between body weight and death outcomes, seriousness of outcomes, demographics and things like that. Jess takes us through it - this study is of 21,551 COVID deaths, but the data that they had about coexisting conditions was based on a limited sample of 1,890 people. So, that’s the number of people they could access medical files for. We have no idea if what we’re seeing in this paper is actually representative of everyone who dies. There’s a lot of missing data, all we’ve got is 8.7% of the total reported. So, in the total (21,551), 35.5% were female. In the smaller coexisting conditions sample (n=1890), 31.9% were female. 12.2% of those who had died had a BMI of over 30, compared to the general population in Italy where 10.9% have a BMI over 30. They should have age-matched information because we know there’s a linear association between BMI and age through to 70 years. As a comparison, 21.2% of this group has chronic kidney failure, which is way higher than the population prevalence. It’s also notable that prevalence of a BMI over 30 is higher in the cohort of women compared to men, however we see here that men were dying much more frequently than women. If BMI related to increased risk of death, we would see that relationship. We’re not seeing it. Compared with other actual serious conditions like kidney failure and hypertension, heart failure, all of those conditions are a higher prevalence compared to that in the general population in those who died compared to the population prevalence of people with a BMI over 30. The weight relationship here is not even slightly interesting when you compare it with these other conditions. And the difference in gender stands out, which we’re seeing across nearly all of these studies that we’re looking at. Maleness and age. COVID can be caught by anyone, but those who progress to a more severe state are typically male and typically older. Comorbidities of various types can also factor in there. There’s a median of 10 days from onset to death in this study - how horrific. A UK paper we’ll be discussing soon looks at how many people were ambulatory - going about their daily lives without needing assistance or their ability to get around being compromised. 98% of the people in the UK data fell into that category before their admission to hospital. If we add that to our Italian data, we’ve got all these people who were out there working, doing grocery shopping, visiting their grandchildren, and then ten days later were dead. Diet culture tells us that if we eat, move, look a certain way we are protected from all sorts of scary stuff. This worry about BMI is that fear again on a larger scale. Following citations in the Malhotra sharticle, Jess went down the rabbit hole and found a paper from Italy published on 5th April 2020, titled “Influenza and obesity: its odd relationship and the lessons for COVID-19 pandemic”. It claimed “Being obese not only increases the risk of infection and of complications for the single obese person, but recent evidence indicates that a large obese population increases the chance of appearance of a more virulent viral strain, prolongs the virus shedding throughout the total population, and eventually may increase overall mortality rate of an influenza pandemic”. The paper then goes on to present three factors which make higher weight subjects more contagious than ‘leans’, one being increased viral shedding. The paper called for higher weight folks to participate in an extended quarantine period as part of COVID 19 response, based on an association that’s been observed in Influenza A. Jess went to look at the paper it sighted, and it notes a relationship between prolonged viral shedding time, Influenza A  and higher weight, but an inverse relationship with Influenza B. This increase in viral shedding time is about one day. When all Influenza strains were pooled together in this study, there was no relationship seen. This data should be extrapolated with caution because COVID 19 is not influenza. We do actually have information about the clearance rates of the virus coming out of China, saying that there’s no difference between BMI bands when it comes to viral clearance. The second factor in this paper that makes higher weight folks more contagious than the ‘leans’ is increased viral load and breath via fine aerosols. Again, Jess followed the citation to look at the primary reference, and after lots of scrolling to the supplementary table saw that there was no statistical association between viral RNA shedding and any of the BMI categories, unadjusted or adjusted. It’s not statistically significant. And yet, they are reporting that this has been a trend that has been observed. SO DODGY. And then the third factor that contributes to increased contagiousness is “obesity results in a more virulent disease with an increased virulence and morbidity”. This paper was citing three papers, two of which were mice models, and the third a cell culture study. They extrapolated findings from those studies back to a human population - big “uh oh”. This paints a picture of a higher weight body as a petri dish for a more virulent virus, and as something that should be feared. It’s a truly horrific paper, and a really dehumanising narrative. Why are these papers citing test tube and animal models? Because they can’t find the same evidence in actual humans. Actual humans get the flu - it’s not as if we can’t observe humans with flu and must instead turn to animal and test tube models to gather information. So much damage can be done with these studies - what are the real world impacts for people in larger bodies? Isolation is terrible for our mental health. If this paper was translated into some kind of public health policy, can you imagine the disaster? The limitations on people’s freedom of movement based on BMI? It makes our blood boil. The paper gives recommendations in their concluding remarks for higher weight folks - including “lose weight with mild caloric restriction”. They also recommend the use of metformin and other glucose modifying drug treatments, and to practice mild to moderate physical activity. The final country on our whistle-stop tour of the planet - the good old UK. Another hotspot for this dreadful virus. Also somewhere with some really fantastic data. The ICNARC (Intensive Care National Audit & Research Centre) has been releasing critical care data weekly, and we now have five weeks of reports to look at. Fiona has been reading these reports each Friday as they get released. We have data on people in intensive care units in a relatively wide are of the UK - who is being admitted to intensive care, who has required lower or higher levels of respiratory support, and who has died. They’ve also given us the background stats (including BMI) for the areas that particular intensive care areas serve. The US data showed us a 50/50 gender breakdown in infection rates. In the UK data we see a much higher rate of males being admitted to intensive care due to COVID - 71.8% of people admitted. We also have data on markers of social disadvantage, conditions that people came into intensive care with, BMI and age. We can see over the five weeks of reports how things have changed - and the reports are additive, so each week’s new data is added to the growing data pool. This means we can see mistakes and assumptions we were making early on as more is revealed. In terms of BMI, there’s no difference between any of the BMI bands until you get to the “over 40” BMI band where there’s a slightly higher representation of people being admitted compared with the background population. That is likely to be an artefact of weight bias - as we discussed with the US data, that admitting staff may be more concerned about higher weight people.` The proportion of people with a BMI over 40 being admitted is dropping every week as more data is collected. We’re looking at three main things with this data. We’ve got people who are admitted compared to the general population. We’ve got people admitted who are receiving advanced support versus basic support. And we’ve got BMI band information, where we can see who in which BMI band needed advanced versus basic respiratory support. In the BMI bands when we look at basic versus advanced support, it’s about 50/50 in all the BMI bands. That would mean that BMI is not driving whether you would need advanced support - it’s not a determinant. If a higher body size meant you needed more advanced support, that would be very clear in this data. Currently in this data we have over 300 people with BMI over 40. It's enough people to see there's no trend. In terms of deaths, we want to know whether larger bodied people receiving medical care die at a higher rate than people in smaller bodies receiving medical care. When the first weekly report came out, it looked like people with a higher BMI were more likely to die versus being discharged from critical care. As the weeks have gone on, that effect has blunted. It’s a phenomenon we call ‘regression to the mean’ in statistics. When you’ve got a small amount of numbers, things can look really significant, and as you add more numbers to that data things look more average. The Index of Multiple Deprivation - categorises people from least to most deprived in society. It’s important to note that the NHS is a public health system, compared to the US health system. In terms of admission based on deprivation in the UK, we’ve got a pretty linear relationship between admission and deprivation. People coming from the least deprived areas have a lower chance of being admitted to ICU (14.8%), and 24.7% coming from the most deprived areas. There’s also a linear relationship with renal support, and with requiring more intensive interventions. This speaks to a background of medical marginalisation. It’s likely these more deprived people are coming in with poorer health to begin with. This pandemic is really revealing inequities in health - it is a stress test on health disparity. That’s what needs to be front page news, rather than fear mongering about BMI. ‘Public health’ is not about health - it’s about housing. It’s about economic access to all things. Equality and safety and opportunity. Dr Malhotra - ‘the root cause of all disease is unavoidable junk food environment’. That’s his take on it. (dick)! From one of the letters to the editor in the Obesity Journal - “The COVID 19 pandemic is challenging the world in an unprecedented way. We at Obesity have been sounding the alarm about the obesity epidemic and now must take up the cause for our patients with obesity in the face of this dual pandemic”. Notice that they offer no advice, no call to action for health services to get better at treating larger bodied people? That’s not actually what they’re calling for. They’re calling for more ‘awareness’, which is a subterfuge for ‘let’s keep up the fat hate’. If they were actually concerned, they would be calling for detailed analysis of how outcomes can be optimized for larger bodied people right now. That's not what they’re doing - they just want the narrative that ‘fat is bad’ to be out there so they can continue selling medication and ‘treatments’ for this ‘equally terrible’ condition. To that we say, “fuck that shit”. Whew, we’re feeling a bit exhausted and jet-lagged from that world journey! Thanks to Fiona and Jess for their hard work, dedication and generosity in digging into all that data and sifting through those papers. (and a special shout out to Fiona who recorded with three children who at one point all stood in front of her having a screaming tantrum) What does this all mean in the bigger picture? Hopefully this has undermined the messages of fear. At the beginning of this recording, we talked about what was firing us up about the corona-crisis. After traversing this territory, what are the take home tips? Fiona says that her take home message is to keep in your sights those people who this is relevant for. If you or a loved one has a higher BMI, Fiona’s advice is to dismiss the headlines. Do not listen to the nonsense of people who have got an ulterior motive to keep you hating your body size. Know that your BMI, if you catch COVID, may be a determinant of whether you get hospitalised or not. But once you’re hospitalised, your chances are no better or worse than anyone else based on your weight. Don’t let anyone spin you the line that you’ve been placed on a ventilator because of your BMI, because based on the data we have right now that’s not true. Jess says her take home message is centered around health disparities and inequities. This is an incredible opportunity for us to dig in once the crisis is over and start to unpick and unpack the different ways in which universal health care like we see in NZ and with the NHS may contrast with the sort of care and access that we’re seeing in the US, such as the ability to pay for care and how it impacts on people’s ability to get treatment where necessary. We here in NZ and Australia are really bloody lucky. No one on the planet has immunity to this virus, and some places on the planet are suffering to a level we can’t even comprehend. Our hearts are going out to you, and we’re really hoping that this ends quickly. Look after yourselves - we will get through this with our bullshit antennas larger and more attuned than ever before. We’re all human, we’re all in this together, and we can do so much better.

Resources

The study from France The Italian study on deaths from COVID-19 The spectacularly garbage study from Italy claiming that larger people are more contagious than smaller people The UK ICNARC data The nephrologists’ website Find out more about Fiona Willer here Find out more about Jess Campbell here