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Clinical Conversations: COVID-19 and Obesity

Learning Objectives
1. Identify interactions COVID-19 may have with patients with obesity
2. Explain how managing stress affects mental and physical health
3. Identify unique clinical challenges and opportunities during this time
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Obesity Medicine Association (OMA) offers clinicians evidence-based obesity management techniques using the four pillars of clinical obesity treatment: Nutrition, Physical Activity, Behavior, and Medication. Learn more

Audio Transcript

Mark Labriola: Welcome to obesity disease, the official Obesity Medicine Association podcast exploring the many facets of the disease of obesity. I'm Mark Labriola. And this episode OMA. Chief Science Officer Dr Harold Bays interviews OMA secretary treasurer, Dr Lydia Alexander, about the impact of COVID-19 and the treatment of obesity. Obesity: A Disease podcast is brought to you by the Obesity Medicine Association, the clinical leader in obesity medicine.

Harold Bays: Welcome. My name is Dr Harold Bays, medical director and president of the Louisville Metabolic and Atherosclerosis Research Center located in Louisville, Kentucky. I'm also the Chief Science Officer of the Obesity Medicine Association. Today we'll be talking about the 2019-2020 Coronavirus disease called COVID-19. Specifically, we're going to be focusing on the patient with obesity, who may be having a mental stress with the COVID-19 pandemic. With us today we're fortunate to have Dr Lydia Alexander. Lydia, why don't you tell the folks who you are and what you do?

Lydia Alexander: So my name is Lydia Alexander and I am an obesity medicine specialist practicing at Kaiser Permanente in San Francisco, California. I was board certified in obesity medicine in 2015, and then recently in lifestyle medicine as well and I've been practicing obesity medicine for close to a decade. I'm the secretary treasurer of the Obesity Medicine Association.

HB: I want to talk a little bit about the physiology then we're going to zero in right on the mental stress aspect. Could you give us, give the folks a little bit idea about your commitment just not just in the lectures you give and what you advise to your patients but your own personal commitment, commitment to nutrition and physical activity. And maybe even stress management what should the folks know about you? Before we get in into your viewpoints about obesity and mental stress.

LA: Well, that's a really good question. Harold. I would say that when I think about physical activity, nutrition and managing mental stress, I think of it as a journey. I think of it as something that is ongoing. It's kind of like doing the laundry—you're never going to really finish doing the laundry or finish you know, checking the mail. Got to do it every single day. And so it's something that should be ideally thoughtfully integrated into life day-by-day and some days you're going to be better at it than others. Sometimes, you know, if I continue with the analogy of washing clothes, you might end up with some pink laundry now and then, but you know, you move on and do the best that you can. So I really do think about tending to our mental health state as an ongoing practice in the same way as nutrition and physical activity, and the two are really intertwined. You know, very intimately intertwined, our mind being connected to our body and vice versa. And so what we do with one really does have effects on the other.

HB: Well, I guess the point I was getting to but I think you made it is that not only is this a professional objective of yours, but it's a personal objective of yours: you do the laundry every day is when I'm guessing. So, uh, all right. Well, let's talk a little bit about the physiology and we're going to get right to the mental stress aspects. When we talk about obesity, I think one of the things we know is that the disease of obesity puts patients at increased risk for adverse outcomes, particularly for upper respiratory tract infection. And that's so important to know when we're talking about COVID-19. There's impairment of both innate and acquired immunity among patients with obesity, impaired lung function, sleep apnea, day or nighttime hypoxia. So you throw an upper respiratory tract infection on there and then that that can be very dangerous to the patient with obesity. You add to that, that obesity can contribute to debilitation and mobility are the orthopedic challenges and such. And, and there's maybe polypharmacy, potential drug interactions, costs, all those things are already a challenge in the patient with obesity. And now you add on top of that, the fact that you have this mental stress of the COVID-19 not just among the folks who experience COVID-19 as a disease, but people who are fearful of COVID-19 that fear or that stress can substantially worse than the diabetes, the hypertension, the cardiovascular disease, impaired immune function, and all of those things when you add it together can potentially increase the susceptibility for a COVID-19 infection, and potentially worsen the outcome. So, I think mental stress and I think, Lydia, I think you said it before, I think that mental aspects of a person and physical aspects of a person are intertwined. I think that's the word you use. If so, how is [inaudible] intertwined? How does stress affect behavior? And how does that pertain to nutrition and physical activity?

LA: Well, Dr Bays, I think that's a great, great, great question. And I love how you summarized the chronic disease of obesity, and how in how it relates to sleep apnea, diabetes, and so many other chronic conditions, chronic diseases, in terms of how stress affects behavior, and specifically, let's you know, take it one at a time nutrition and then physical activity. The, you know, stress affects us in a number of ways and if we take a step back—not all of them are really that bad. There's a dose response relationship curve over time. So for instance, acute stress is really beneficial. And that's why we're hardwired to have a stress response, an anxiety response, even if you will, but chronic stress marinating in our stress hormones over prolonged periods of time, can have deleterious effects on our body so—

HB: People know what you're talking about, fight or flight, can actually be beneficial to people who got it, but it's that submit in stay. Not so good a lot of times, right, that chronic stress—

LA: Yes, bingo. Exactly, exactly. And so it's when this acute stress continues, going on over long, long periods of time, that that it starts to affect our body in negative ways. And so in insofar as nutrition, always being in this go mode, and so forth, for instance, can affect our sleep. And we know from studies that poor sleep increases different hormones hunger hormones, for instance, like ghrelin, that that have us wanting to you know, to eat more and in this is going back in time, a response that had some benefit which it no longer has much of that benefit anymore. And so that's one way in, in that you know, stress can lead to poor sleep and then this can increase hunger and so that may not be beneficial to us right now. Other comfort eating for instance, is another example of how stress can affect our behavior and lead to poor nutrition.

HB: Can you give me example? When you talk about comfort eating what do you mean?

LA: So eating familiar foods, you know, eating many times easy to access foods are easy to prepare foods so we don't want to you know, spend perhaps a lot of time doing that we feel stressed out. We want, you know, to take care of something right away instant gratification in so far as COVID-19 right now and this pandemic, you know, where many of us are trying to limit our trips even to the grocery stores. And so this means that we're eating more nonperishable foods. And so they're processed for a long shelf life. And so we may be favoring these processed foods and in addition to that simple carbohydrates and so when you have these simple carbohydrates, they can release dopamine. And this gives us a quick short-term reward. And so there's some research also shows that this stress response is an effort to activate our parasympathetic nervous system and move us out of that anxious fight or flight state. And in so, you know that stress eating is sort of the body's effort to say, Okay, I don't want to be anxious anymore. I want to calm myself down. When I do this, I get a dopamine rush, this hedonic eating, while it may feel like the right thing to do in the short term, is maladaptive long term.

HB: All right, and One of the things that I think all, hopefully people heard at the very beginning, so I'm calling from, I'm calling from Louisville, Kentucky, you're located in San Francisco, California. And I think the environments that are I mean, look, it's very stressful here. It's very difficult here, but it's nothing like California, it is not. And at the time, we're doing this taping right now. We are still increasing in the number of new COVID cases, it looks like there may be a possibility of some peeking again, right at this time. But coming from California, and when you know, we hear things in other parts United States about I mean, we're having to stay home but not anything like California. Can you tell us a little bit about what does that experience like and particularly what is it like when you're trying to engage in routine physical activity? Can you give the folks a sense about I mean, what, what do you recommend your patients there in California, and how have you found personally that you can deal with this?

LA: Well those are again really good questions. We're at a moment in time which has not really happened arguably since the Spanish flu and 1918 and shelter-in-place it's not a, you know, it's not a staycation at because we cannot go about doing the those you know, some of the you know, more familiar forms of physical activity that we may have enjoyed, such as playing tennis. The parks are closed, place structures are closed in our community there. There's, you know, the yellow orange tape around it saying warning, caution, you know, police line do not cross and, you know, Californians are taking shelter-in-place very seriously in order to bend the curve. And that makes a lot of sense. At the same time. It can be very challenging to find ways to, to healthfully engage in movements and physical activity exercise. Some of the ways that we're doing it here is in our communities. We are allowed to, to walk outside, go for walks on the street, as long as we maintain a 6-foot distance from one another, even though the beaches are closed, as I mentioned, in parks where we can't go, we can certainly still walk around this way. You know, fortunately, in 2020 versus 20 years ago, we do have a lot more, you know, connectivity through the internet. And so there are exercise videos on YouTube that we can access a lot of different ways to do that. There's a difference between what we call social distancing and I personally prefer the term physical distancing. I think social distancing feels very isolating, especially for our younger population, who, who spend a lot of time on social media are very connected with each other that way, and so I like the term physical distance, because that's really what we're trying to do here. We're trying to be socially connected, but physically distant until we can bend this curve—

HB: Let me just interrupt here. That is so important because what you said there and you just kind of just flew right by, and it sounded like perfectly normal to you. I'm sure they're in California. But when you said, you know, we're still allowed to walk in the park.

LA: Well, on the streets, I got to tell you

HB: That is surreal, or the streets or the parks or whatever. That just that is surreal. I mean, again, I think we've come just in the in the several weeks since this all began, we've already adapted to the sense Well, yeah, we're still allowed to walk on the streets. I mean, I just find that to be extraordinary. Yeah. To me, and being there in California. I mean, again, it's I think it's quite remarkable that you've, you've adapted so well to this. This is until it—I guess the point I'm making is that goes back to what you were saying before, the importance of characterizing this as physical distancing and not social distancing. Because oh, my gosh, I mean, what are we talking about here?

LA: Yes, it's so true. And I think that's really… Because I will say as a specific example, well I'll make 2 specific examples. So when we're practicing our physical distancing, so that we avoid infection with COVID-19, or infecting others, I pass my neighbors on the street, and I say hello to them. And we're cordial to each other, we greet each other. And that is a social connection that we are making. And it feels good, even though we're keeping our physical distance. And so those are little nuggets that we're just trying to, you know, to hang on to. And, for instance, another very, very funny—and I'd love to find some way to make it happen in my community as well—in Marin County, north of San Francisco at 8pm, every night, those residents are coming out on their porches and having a social moment where it's a community howl. And so they were just howling at each other and, and having sort of a communal, a community moment there and I think we've heard about that in Italy to where there's, you know, singing from the balconies and that type of social interaction, which is so mentally important at a time like this when we, when we can feel very disconnected in--

HB: Here in the south and Kentucky we call it holler. So we've been doing that for some time. Okay, I'm sorry, go ahead.

LA: And so you know, so you have your, your physical distancing, to avoid infection. And then for those of us I mean, this really hits close, you know, close to home for me personally, because I'm COVID-19 positive.

HB: However, having said that, it I'm sorry, say that one more time

LA: I'm COVID-19 positive. So my husband and I tested for the SARS Covid virus and we do have it and we were confirmed positive a few weeks ago. We're just coming out of quarantine right now. And I'll tell you the feelings of you know, social isolation in addition physical isolation can feel really real when we become that limited in our ability to move about and you know, it's house arrest is what it can feel like. And so trying to make lemonade out of those lemons and thinking about ways to socially connect through for instance, last night we had a zoom cocktail party with our friends and some zoom playdates for our kids have been in the works this week as they're on their spring break. And then ways to stay, you know, physically active. I am I have a hula hoop I'm a big fan of hula hooping and, and so, trying to find ways to in a close, you know, enclosed space to move around and is I think really important because it improves mood and improve sleep and it could also affect then our hedonic eating patterns and, you know, and habits sort of a virtuous upward cycle as opposed to this sort of downward feeling of helplessness and, and feeling stuck or caught.

HB: I think that's so important because when we, we have patients with the obesity many times, they already had mental stress before this whole COVID-19 thing even started. And then you add on top of that, the, again, not just the infection aspect, but the mental stress of potentially becoming infected. And now, maybe the obesity gets worse and the blood sugar get worse, the blood pressure gets worse and maybe the lipid levels get worse and maybe the sleep gets worse and, and you add all those things together. Well, I'll just ask you: So let's say you do have a patient with obesity. They are stressed to the max with the fear of COVID-19. They're not handling the being at home all the time situation and maybe they're already in the comfort foods, maybe not doing all the things that you've talked about and moving around in the house and maybe in some places they can't go, don't have the freedom to go outside and do those types of things. I mean, what do you tell the folks? What has been your approach when you when you have patients with obesity that are coming face-to-face with this this COVID-19 nightmare? What? How do you how do you help them cope?

LA: We go back to I think one of the most important things to go back to is to think about short term versus long term and to make sure that we maintain hope it's so easy to lose hope right now and to feel as though every time you know, every minute that you know there's we hear about a death. We hear about an unfortunate circumstance; we hear about how the pandemic is expanding how more people and more countries are affected and resources aren't there for health care workers and so forth. And I think it's important to take a step back and to try to find where you know where is that hopeful nugget in this situation. And it's not going to last forever. We're going to get through this. We're, they got through the Spanish flu. And we've gotten through a lot of other tough situations. And you will get through this, we will collectively get through this. And what can we do in the meantime. And so I think some helpful behaviors, in so far as managing stress, which, you know, stress increases cortisol, which then increases glucose in the body can worsen prediabetes, diabetes, I can, as you mentioned, Dr Bays, decreased immune function, and so what can we do to proactively put ourselves in a better place? And I think a few of the tips that I you know, I practice them I give them to myself, I talked to myself about them as I do to my patients is, one is, you know, maybe budget, your news consumption. There's very little on the news that's going to have an immediate impact. on us, and so perhaps, you know, don't watch the news within two hours of sleep, you know, we know that we get better sleep we wake up or better able to manage the next day, consider I call it using a palate cleanser, just after watching the news. And what does that mean? You know, watching something that will pull your mind away from the COVID pandemic, something they'll make you laugh, perhaps, or maybe something that you'd like to learn, or maybe even watching prior sports season could work. You know, don't underestimate you know, those types of behaviors that can put us into a negative cycle and those that can, you know, kind of get us out of it. So I do tell patients about that. And about having positive distractions and active distractions. What do you tell your patients, Dr Bays?

HB: I mean, I think it's pretty similar to you, but I mean, the things that has frustrated me the most is, there seems to be a prevailing opinion. That if you give any patient hope that that's a really bad thing to do. Okay, that's a really, that's really dangerous ground because the minute you give somebody hope, then there is this calculation that people are going to do. You're not going to hear to the distancing that you talked about are not going to hear to adhere to the hand washing and such and that's, maybe that's true for a very small number of people. But I think there's a lot of other people that could truly benefit from a message of hope, a prescription of hope.

And I read an article, it was actually published in San Francisco, where some of the data is either not being given or in some way, in some places, taken away. Because at this point, it's hopeful. And there is a calculation that if they put out hopeful messaging in the news, just like you mentioned, that people are going to, you know, that it's somehow going to have an ill effect and, and I just don't agree with that at all. I think we here enough about the and rightfully so about the tragedies and the deaths, many of our, our friends and colleagues in the health care profession have died. I mean, that's, that's tough. It's tough to find a positive out of that. But at the same time, I just don't see the benefit of just day to day, hour to hour, minute beat downs of people's psyche, I just don't get it. And now in the topic of what we're talking about today, we have patients with obesity, that are so susceptible to the real physical ramifications of mental stress. The idea that we can't just give a little hope that somehow that's a bad thing. I just don't agree with that. So anytime that there's an opportunity for me to say, hey, look, if you look over there in Europe, some of the countries that were the hardest hit, looks like they've gone over their peak, at least that's what it looks like right now. And maybe if you look at the, you know, the Hopkins data looks like we might be at a peak. Maybe we're not the maybe we are, I think sometimes kind of throwing out those things, particularly if you're engaged with telemedicine conversations, the idea that you can give people hope, because what did you just say? Who said we're going to get through this? Well, sometimes people don't need to know that that's true. People need to have a, a sense of reality or, or some sort of evidence that it's true. And that and the idea that we're going to withhold that evidence or withhold that information from people because we're scared of what, you know, a few people are going to do. I just think that's wrongheaded. I mean, you're in California, you tell me – what do you think?

LA: Hope is helpful. Hope gives us a vision for the future that makes us want to persevere and do the right things, and contribute in a meaningful way that you know is going to make the next day better and the next day after that better, I completely agree with having hope not extinguishing hope, especially now, as we mentioned, with social isolation, being a real thing, because we can be physically distancing as we mentioned, but then the social networks can also So diminished and that can be difficult. I think that having hope, you know, keeps us going even if every day is not the best day we've ever had, even if we sometimes turn our laundry pink as it were, that we can continue and, and make the most out of it. And so, some ways that I, you know, I do this for myself and again, at practice, what I preach and in for my patients as well, is to make the most, you know, make the most out of social outreach. And so connecting with people, I think, on an emotional level, not just surface level, social connection, but deeper, you know, my voice like we're doing today, through a phone call, or voice and face on a video call video conferencing as opposed to perhaps texting or, you know, sending each other emojis which is more superficial and may not give us that deep social connection that we're yearning right now. Another thing to do, which I may have alluded to earlier, is feeling that we have an internal locus of control so that we are actively accomplishing something. So if you have time now you can do things you've always wanted to do, for instance, like learn more about, I don't know, astronomy, music production, how to become a DJ, something else.

HB: I'm going to be revising our policies and procedures.

LA: Yes, that's very exciting. Indeed, indeed. And, and so having that sense of purpose that you're talking about right now is really, really important. And I think that there's also a way to intertwine social connection with purpose. So reach out to someone in your community and make a difference in their lives. Is there an older adult who lives near you who may be afraid to go to the grocery store? Can you help them? Can you drop off groceries at their doorstep? Can you help someone else who is fearful, much in the same way that you are, and help talk them down from that help, you know, be a sounding board, perhaps they're concerned about a loved one as I am, I'm concerned about my 85-year-old mother with chronic conditions, and what will happen if she becomes infected with COVID-19. So there's a lot that we can do there, you know, to, to help people feel better. And in, in, in, in return it also provides us with that social connection that we may be yearning for.

HB: Well, I think that's a good way to end, and I think my takeaway here—I mean, we honestly you know, we started off the conversation talking about the physiology and then we talked about the integration of mental stress and how it affects a person's metabolism and focused on the patient with obesity and, and then you've given some advice on how to manage that mental stress and manage that nutrition and that physical activity in the most challenging of circumstances where you're being required to stay home and everything. And at least what I'm hearing from you where we ended up is we're talking about hope and how to be better people.

LA: That's right. And then the wonderful effects that that can have on our, on our stress levels, it can decrease them. This improves health. This improves perhaps our eating patterns as well. And in physical activity being also very important in keeping us having hope and keeping our mental stress under control.

HB: All right. Well, thank you very much, Dr Lydia Alexander. And again, my name is Dr Harold Bays, and you've been listening to the Obesity Medicine Association podcast on COVID-19 and obesity.

Mark Labriola: Thank you, Dr Bayes, and Alexander. For more information about obesity medicine, podcasts, and other resources from the clinical leader in obesity medicine, please visit obesitymedicine.org/podcasts. Love this episode of Obesity: A Disease? Head over to iTunes and subscribe, rate, and leave a review. The views expressed in this podcast episode are those of the show hosts and do not necessarily represent the opinions, beliefs, or policies of the Obesity Medicine Association, or its members. Please check back soon for another episode of Obesity: A Disease.

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