Transcription:
Obesity and COVID-19 Complications

Caitlin Whyte (Host):  Studies have reported that many of the sickest COVID-19 patients have been people with obesity. To narrow that down, researchers have found that people with obesity who contract SARS COV2 were 113% more likely than people of healthy weight to land in the hospital and 74% more likely to admitted to an ICU and 48% more likely to die. Today, we are talking weightloss and obesity in the era of COVID-19 with Dr. Nirav Naik, the Director of the Bariatric Surgery Program at Mercy Hospital Bakersfield. So, Dr. Naik, we’re talking about obesity and COVID-19 but what are some other comorbidities that are associated with obesity that may complicate this virus?

Nirav Naik, MD, FACS (Guest):  So, there is a whole list of things that obesity is related to all on its own. Things that can really make it worse when you have the infection have to do mostly with your lungs. First of all, when you have obesity, there is a condition known as Pickwickian and hypoventilation syndrome and that’s at baseline. That’s people who are obese just in general. What happens is that they tend to retain carbon dioxide so they can’t breathe it all out and that diminishes also their ability to exchange the oxygen as well.

And so if you already have an underlying lung problem, at baseline, obviously anything that’s going to affect your lungs is going to make that exponentially worse. The other condition that is associated with this is sleep apnea and that’s very closely related to this and sleep apnea is essentially where you stop breathing at nighttime and even though you are already not ventilating well, as soon as you are in the recumbent position, when you lay down flat, all that weight from the abdomen now is pushing up against your lungs. So now your diaphragm can’t push against all that extra weight and so you basically just stop breathing. And then eventually, you end up making this very loud snoring breath to wake yourself up. How you end up waking yourself up but when this big loud snoring breath happens, it’s very jarring and you can hear that sometimes. People don’t know they are doing it frequently. Their spouses are the ones who notice this quite regularly. You wake yourself up pretty aggressively and break yourself out of REM sleep. So, it’s very common for patients to say like you know I sleep eight hours, but I never really felt like I got a good night’s sleep.

CPAP machines can help. Probably about 50% of the patients that I see that come through my office have some level of sleep apnea. Diabetes is another risk factor. And that’s also very common in our population. A lot of our patients are either diabetic or prediabetic or have some level of sugar abnormality that a lot of times goes undiagnosed. When the sugars go high, that diminishes your body’s ability to fight infection. It also changes the ability to manage fluids effectively in the body. A lot of times when patients are initially diagnosed with diabetes, they lose weight because their bodies are basically starving the blood sugars are very high. The kidneys will excrete that extra sugar in the urine, and it creates what’s called an osmotic diuresis where basically, it tries to even out the concentration of the urine, so you end up draining a whole bunch of fluids, so you are chronically dehydrated. So, that can also make things worse when you are acutely ill in the ICU.

Host:  Now focusing on people who carry a lot of abdominal fat in particular, how does that affect their lungs and how they breathe?

Dr. Naik:  Patients who have a lot of abdominal fat really have a much harder time breathing. This kind of touches on the Pickwickian syndrome and sleep apnea. In the supine position, when you’re laying flat, what happens is that your alveoli which are the breathing sacs, the air change sacs are basically flattened out especially when you’re in the ICU, or during surgery or you’re recumbent or you are sick, basically the lungs end up flattening out and that is a much higher surface area where that happens and so it makes it even harder to exchange gas. Now you are pushing on a ventilator against this heavy abdomen and it increases the pressure, and it makes it much more difficult to exchange gas.

One of the things that’s interesting is during the late 90s, I did a lot of trauma surgery and these people had severe respiratory illnesses sometimes and what we found is that making them prone from a supine to a prone position, so on your back to on your stomach actually recruited all of those collapsed alveoli and fortunately, we started doing that very early on in the COVID experience and now we’re seeing improved ventilation when patients have their positions changed. Now unfortunately, when you are obese, that makes it far more difficult because literally, you can’t move somebody as easily so that might make them even more prone to not being turned as often or as effectively making it more difficult to use this treatment when they are sick and on the ventilator in the ICU.

Host:  Now talk to us about the clotting risks in COVID patients who are also obese.

Dr. Naik:  So, COVID-19 first of all is a very unusual disease. This does not act like the flu virus in many ways. And we’re seeing aspects of this disease which quite honestly, we’ve never seen with any other coronavirus, rhinovirus or any of the other commonly occurring viruses. One of the things that’s interesting about it is it seems to cause a lot of inflammation in the blood vessels. And you’ve heard the reports of COVID toes, where kids now have purple toes and are losing blood flow to that. That process of injury to the vessel lining is occurring far more regularly. What that leads to is irritation of the lining of the veins also and that can lead to a blood clot developing. That blood clot can develop and grow and then break off and go to your lungs. When that blood clot goes off to your lungs, it’s called a pulmonary embolus and that can literally kill you. Because if it’s a big enough blood clot, it will cut off the blood flow to your lungs.

Now this is common problem in our bariatric population already. In fact, death by a pulmonary embolus is the number one cause of death after weightloss surgery. So, it’s something that I am very, very cognizant of and I take every precaution to try to minimize around the time of the surgery. And fortunately, that risk is very low because I take very, very, sorry minimize the risks as much as possible. So, now when you already have a condition like COVID-19 that puts you at a risk baseline and you are already obese, you are not mobbing around, the leg calf muscles are not pumping the blood through because you’re laying down flat in an ICU bed; that further increases the risk to that. Obesity by itself, is a proinflammatory condition. We’re not sure why some of these things occur but that also does increase your risk of getting blood clots all by itself, then the extra weight on the blood vessels to the legs and thighs from the extra fat minimizes the ability for the blood to get through towards the heart. And especially if you have a large abdomen and we see this more in males where they have more of an apple type shape where most of the weight in in the abdomen.

All that extra weight is pushing down now on your back when you are laying flat and against your vena cava so now all that blood from your legs is having a harder time getting through your abdomen because there’s an added level of pressure. All of those things put together, put you at a much higher risk for such a serious complication.

Host:  Now how does obesity compromise the immune system and how can that contribute to a more severe COVID-19 illness?

Dr. Naik:  So, obesity by itself, does suppress the immune system and the exact mechanisms by which it does that are not exactly clear and most likely are fairly multifactorial. There are multiple reasons why that may be. That may be related to changes in cortisol suppressing the immune system but more often what we see is changes in sugar concentration such as diabetes or prediabetic conditions. Those are very well known to decrease white cell function. Which are the infection fighting cells in your blood. So, now as it with an elevated blood sugar, your white cells can’t fight as effectively and now you’re more prone to getting various infections. Obesity by itself, has also been shown to decrease various cytokines or some of the chemical signals between the blood cells. The function of the certain kinds of white blood cells such as monocytes and lymphocytes which are the ones that are mainly used to fight viral infections not bacterial infections along with natural killer cells which are usually used to help us fight against cancer, there’s markedly diminished function in those with just obesity by itself.

And now when you have an other condition that puts you at risk, these all become additive. So, when you’re obese you’re already natively immunosuppressed so that you’re more prone to being ill from such a severe disease. The other thing also that has been related to the obesity and immunosuppression again, this is the chicken, or the egg theory why is that. Is it because of the diet causing it? Or is this causing changes in your diet? The one thing that has be shown is that changes in the diet such as decreasing the amount of simple sugars in the diet really have been shown to improve blood sugar function and therefore immune function as well. Having elevated levels of simple sugars will increase inflammation in the body and we’re seeing more and more that many disease states in the body are directly tied to whole body inflammation.

For instance, fructose which is the sugar that you find in fruit, this is actually one of the most inflammatory sugars in the body. We’re not saying that eating fruit is bad. But eating raw fruit when you have fiber and other things that are in there, they kind of meter the effects so that it’s not as inflammatory. However, when you get rid of the pulp and everything else that’s in the fruit, and you just drink the straight refined juice; those things aren’t there so believe it or not, fruit juice is probably one of the worst that you can ever drink. So, again, changing your diet a lot of times will have a profound effect on how your immune system responds and also the effects on your weight. This is one of the reasons behind some of the eating programs such as intermittent fasting and KETO diet, some of the lower carbohydrate diets. That’s what is based on this and there’s a mounting body of evidence to show that intermittent fasting and markedly diminishing simple or refined sugars in the diet have tremendous health benefits and proinflammatory effects.

Host:  There are numerous benefits to weightloss surgery. But can you tell us how bariatric surgery may be even more crucial during this time of COVID?

Dr. Naik:  So weightloss surgery in general, has had a pretty significant stigma associated with this traditionally. People have looked at weightloss surgery as sort of a fringe procedure and almost as a sign of weakness as patients who can’t control themselves. I always view weightloss surgery not as a cure but as an effective treatment to help modify patient’s lifestyles as well. When lifestyle modification does not occur, weightloss surgery by itself does not work. That being said, we already know that obese patients with significant associated illnesses have a much higher chance of being ill or possibly dying as a result of COVID-19. During the initial shutdown of elective surgeries during this initial phase of the pandemic, weightloss surgery was considered one of the elective surgeries. I fought very hard to turn that around because I don’t look at it as such. When you look at patients who are being able to lose even a nominal amount of weight, even before looking at the pandemic, most of them were already seeing improvements in their blood sugars, they’ll see improvements in their breathing, say heh you know, I’ve lost 15 pounds and I don’t need my CPAP as much anymore.

These marginal improvements they seem like they’re little, it’s only 10 or 15 pounds for some people but the health benefits are quite high. Now, if you take somebody who has all these issues and gets COVID, it’s very different from somebody who has improved their situation whether it be by natural means or with the assistance of surgery; their survival is going to be greatly improved. So, the stigmata associated with doing weightloss surgery I think has to be changed. And when you look at weightloss surgery, I look at it as a very vital tool to limiting COVID-19 outcomes. Basically, I think we have to change what our view is on COVID-19. I don’t look at it as whether we’re going to get COVID-19 or not. I look at it as when are you going to get COVID-19. I honestly feel we’re all going to get it. I don’t think a vaccine is going to be around in time. And there really isn’t an effective treatment regimen at this point.

We can limit the spread but unfortunately, I think at some point all of us are going to get it. So, the way I look at weightloss surgery is this. Is that I would much rather have you get COVID at a lower healthier body mass and more likely to survive it or have a less severe course of disease than if you’re at a higher body mass index. So, therefore, I think doing bariatric surgery is not only not elective I think this is potentially a life saving procedure for patients affected by obesity so that when they finally do get, hopefully they don’t, they are more likely to do well as opposed to do poorly.

Host:  So, if someone is considering weightloss surgery, what should they do to take that first step?

Dr. Naik:  The first step is to have a very frank discussion with both their families and with their primary care physician. A lot of the changes that occur around the time of weightloss surgery has to do with significant changes in one’s lifestyle. And when one is committed to making those changes, the results of weightloss surgery are going to be long lasting and you need the help of people around you. You literally cannot do it by yourself. And when you talk to your primary care physician about it, they can submit a referral to our weightloss program, or you can actually make that referral by yourself and directly contact us and we can get that process facilitated.

Unfortunately, a lot of primary care physicians even today, also fall into that stigma with weightloss surgery and I can’t tell you how many times patients have be frustrated with their primary care doctor saying well you just need to diet and exercise. Well quite honestly, if they could have done it effectively, they would have done so already. And so, I always look at it as a combined approach. People who look at just doing diet and exercise in the morbidly obese population, the success rate is only 5%. When you look at patients who don’t make any lifestyle changes and they just have surgery, the recidivism rate is, the chance they are going to gain their weight back is significantly higher in those patients pushing upwards of 50%. But still 50% that’s better than 5%. But at the same time, the important thing to remember though is that when you combine both those approaches, making sure that healthy lifestyle changes are performed as well as doing surgery; then the likelihood of having a prolonged successful outcome is much higher.

So, contact your primary care physician, have a frank discussion with your family or call us directly and we can get the process started.

Host:  What would be some of the immediate benefits then for these patients medically speaking?

Dr. Naik:  For a lot of these patients, who especially those who are diabetic, have high blood pressure, for instance sleep apnea and are on CPAP machines, the benefits really are immediate and certainly for certain surgeries like gastric bypass, patients who are diabetic frequently aren’t diabetic by the time they leave the hospital. The whole goal of doing these surgeries is not to lose weight. The whole goal of these surgeries is to get you to a healthier place. And a lot of our patients are on a basket of medications on a daily basis and looking three to six months out, many of these patients are completely off their medications, they are off their diabetes medicines, they are off their high blood pressure medicines. They got rid of their CPAP machine. And they are off their cholesterol pills. All of these things can be performed successfully with successful weightloss surgery and lifestyle change.

So, frequently you’ll see these benefits present themselves within a month of surgery. So, even if we can get you off these medications which by the way a lot of them have side effects which we don’t really talk about too much. We can get you off these medications and get your body in a better natural functioning state, again, you’re going to be healthier and you’re less likely to subject yourself to a bad outcome with COVID infection.

Host:  Now wrapping up here. Is there any data that supports the benefits of weightloss surgery for those persons at a higher risk of becoming critically ill or dying of COVID?

Dr. Naik:  So, that data isn’t exactly available just yet. Because it’s going to take a little time for us to be able to see what happens and I think it’s going to be really interesting to look at the beginning of the year, looking at the first three months of this year from January to March when the shutdown happened and elective surgery was stopped and looking at what happened between those couple of months when we were shutdown and we were not doing bariatric surgeries. That’s going to take time for us to be able to parse through that data. But going over the things that we’ve talked about it stands to reason that I think that that’s going to show a very strong benefit to having weightloss surgery.

Unfortunately, the process by which weightloss surgery gets approved is very frequently dependent on the insurance companies and there’s a very substantial wait period between three to six months I’ve seen some insurances that make you go through a medical weightloss program for up to a year. And some of those things I think probably are not as necessary. I am very thorough with the work up of my patients to make sure that they are in the best condition they can be, and I examine them with every test possible to make sure that they’re good candidates for an operation to help them lose weight.

Because we don’t consider them emergent surgeries so I try to safeguard them as well as I can. Unfortunately, some of those things do take time and usually we have some months to do so. Unfortunately, certain tests are just not being performed either at the hospital or the outpatient basis and that can delay the approval for the surgery process. So, I’m doing my best to try to streamline some of those things and doing what’s absolutely necessary so we don’t have any needless delays so that we can get these patients to surgery as quickly but as safely as possible so that we can minimize the potential effects of COVID around them.

Host:  Great Dr. Naik. Is there anything we didn’t touch on in this conversation that you want to make sure listeners know?

Dr. Naik:  I guess the main thing I want to be able to tell people is this that weightloss surgery is not a free ride, it’s not a way out, it’s not a quick fix to anything. Weightloss surgery is a commitment and certainly when that is paired with healthy lifestyle change, that we can get you to a much healthier place both for yourself and for your family. And also make sure that you’re there for your family so that if you do get COVID, we’re in a position that we can actually survive this and come out in a much better condition than you would be otherwise.

So, the data really is showing that the link with obesity and the risk factors for illness or mortality of COVID-19 infection are very strong. I just saw an article actually the other day looking at the risk stratifications for who is going to develop severe disease. One of the most common risk factors in there was a body mass index over 35 and unfortunately, this is somebody that who I know, this is somebody who I had seen at a socially distanced gathering probably about two months ago and unfortunately, he is a few years older than me, I’m almost 50 and he is obese, has diabetes and I actually talked to him about this very phenomenon and he said yeah I need to do something. But unfortunately, he’s in the ICU right now and he’s been in the ICU on a ventilator now for almost two weeks. So, this hits pretty close to home and this is case in point that people who have obesity and other comorbidities are far more prone to a more severe form of the disease.

Host:  Thank you so much for this critical and urgent information Doctor. That was Dr. Nirav Naik, the Director of the Bariatric Surgery Program at Mercy Hospital Bakersfield. To learn more about weightloss surgery options at Mercy Hospital, visit www.dignityhealth.org/bakersfield/weightloss. Or call 661-632-5117. That’s 661-632-5117. Find more interesting and informative podcasts in our podcast library and be sure to share them with your loved ones. This has been Hello Healthy, a Dignity Health Podcast. I’m Caitlyn Whyte. Stay well.