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Is substantial weight loss achieved with weight loss surgery associated with improved risk and severity of COVID-19 infection in patients with obesity?
In this cohort study of 11 809 patients with obesity, the rates of positive SARS-CoV-2 test results were comparable among patients in the surgical group and control group. However, previous weight loss surgery was significantly associated with a 49% lower risk of hospitalization, 63% lower risk of need for supplemental oxygen, and 60% lower risk of severe disease during a 12-month period after contracting COVID-19 infection.
The findings from this study show an association between weight loss achieved with surgery and improved outcomes of COVID-19 infection, suggesting that obesity can be a modifiable risk factor for the severity of COVID-19 infection.
Obesity is an established risk factor for severe COVID-19 infection. However, it is not known whether losing weight is associated with reduced adverse outcomes of COVID-19 infection.
To investigate the association between a successful weight loss intervention and improved risk and severity of COVID-19 infection in patients with obesity.
Design, Setting, and Participants
This cohort study involved adult patients with a body mass index of 35 or higher (calculated as weight in kilograms divided by height in meters squared) who underwent weight loss surgery between January 1, 2004, and December 31, 2017, at the Cleveland Clinic Health System (CCHS). Patients in the surgical group were matched 1:3 to patients who did not have surgical intervention for their obesity (control group). The source of data was the CCHS electronic health record. Follow-up was conducted through March 1, 2021.
Weight loss surgery including Roux-en-Y gastric bypass and sleeve gastrectomy.
Main Outcomes and Measures
Distinct outcomes were examined before and after COVID-19 outbreak on March 1, 2020. Weight loss and all-cause mortality were assessed between the enrollment date and March 1, 2020. Four COVID-19–related outcomes were analyzed in patients with COVID-19 diagnosis between March 1, 2020, and March 1, 2021: positive SARS-CoV-2 test result, hospitalization, need for supplemental oxygen, and severe COVID-19 infection (a composite of intensive care unit admission, need for mechanical ventilation, or death).
A total of 20 212 patients (median [IQR] age, 46 [35-57] years; 77.6% female individuals [15 690]) with a median (IQR) body mass index of 45 (41-51) were enrolled. The overall median (IQR) follow-up duration was 6.1 (3.8-9.0) years. Before the COVID-19 outbreak, patients in the surgical group compared with control patients lost more weight (mean difference at 10 years from baseline: 18.6 [95% CI, 18.4-18.7] percentage points; P < .001) and had a 53% lower 10-year cumulative incidence of all-cause non–COVID-19 mortality (4.7% [95% CI, 3.7%-5.7%] vs 9.4% [95% CI, 8.7%-10.1%]; P < .001). Of the 20 212 enrolled patients, 11 809 were available on March 1, 2020, for an assessment of COVID-19–related outcomes. The rates of positive SARS-CoV-2 test results were comparable in the surgical and control groups (9.1% [95% CI, 7.9%-10.3%] vs 8.7% [95% CI, 8.0%-9.3%]; P = .71). However, undergoing weight loss surgery was associated with a lower risk of hospitalization (adjusted hazard ratio [HR], 0.51; 95% CI, 0.35-0.76; P < .001), need for supplemental oxygen (adjusted HR, 0.37; 95% CI, 0.23-0.61; P < .001), and severe COVID-19 infection (adjusted HR, 0.40; 95% CI, 0.18-0.86; P = .02).
Conclusions and Relevance
This cohort study found that, among patients with obesity, substantial weight loss achieved with surgery was associated with improved outcomes of COVID-19 infection. The findings suggest that obesity can be a modifiable risk factor for the severity of COVID-19 infection.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Accepted for Publication: October 7, 2021.
Published Online: December 29, 2021. doi:10.1001/jamasurg.2021.6496
Corresponding Author: Steven E. Nissen, MD, Cleveland Clinic Coordinating Center for Clinical Research, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Ave, Mail Code JB-20, Cleveland, OH 44195 (email@example.com).
Author Contributions: Dr Aminian had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Aminian.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Aminian, Milinovich.
Critical revision of the manuscript for important intellectual content: Aminian, Tu, Wolski, Kattan, Nissen.
Statistical analysis: Tu, Milinovich, Wolski, Kattan.
Obtained funding: Aminian.
Administrative, technical, or material support: Aminian, Nissen.
Supervision: Aminian, Nissen.
Conflict of Interest Disclosures: Dr Aminian reported receiving research support and speaking honoraria from Medtronic outside the submitted work. Mr Milinovich reported receiving grants from NovoNordisk, Novartis, Boehringer Ingelheim, Merck, Bayer, National Institutes of Health, and the National Football League Players Association as well as personal fees from American Association for Thoracic Surgery outside the submitted work. Dr Nissen reported receiving grants from Novartis, Eli Lilly, Abbvie, Silence Therapeutics, AstraZeneca, Esperion Therapeutics, Amgen, and Bristol Myers Squibb outside the submitted work. No other disclosures were reported.
Funding/Support: This study was funded by grant ERP-2021-12614 from Medtronic.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Meeting Presentation: This study was presented in part in the Latest Science Session at the European Society of Cardiology Congress; August 27, 2021; online.
Additional Contributions: Greg Strnad, MS, and Robert Burton, BS, Cleveland Clinic, helped in the collection of some data. These individuals received no additional compensation, outside of their usual salary, for their contributions.
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