Keywords

Conflicts of interest: All authors report that they have no potential conflicts of interest.

Acknowledgements: We would like to thank Li Shi, Wenwei Xiao, Xuan Liang, Jian Wu, Peihua Zhang and Yang Li (All are from Department of Epidemiology, School of Public Health, Zhengzhou University) for their kind help in searching articles and collecting data, and valuable suggestions for analyzing data.

An updated meta-analysis on the relationship between obesity and COVID-19 mortality

Recently, Huang et al published an article titled “Obesity in patients with COVID-19: a systematic review and meta-analysis” in the journal of Metabolism [[1]Huang Y. Lu Y. Huang Y.M. Wang M. Ling W. Sui Y. et al.Obesity in patients with COVID-19: a systematic review and meta-analysis.]. The authors reported coronavirus disease 2019 (COVID-19) patients with obesity were at high risk for death based on seven studies with multivariate analyses (odds ratio = 1.49, 95% confidence interval (CI): 1.20-1.85) [[1]Huang Y. Lu Y. Huang Y.M. Wang M. Ling W. Sui Y. et al.Obesity in patients with COVID-19: a systematic review and meta-analysis.]. This study was greatly interesting, but had limited sample sizes. In addition, several eligible studies [2Deiana G. Azara A. Dettori M. Delogu F. Vargiu G. Gessa I. et al.Deaths in SARS-Cov-2 Positive Patients in Italy: The Influence of Underlying Health Conditions on Lethality., 3Hashemi N. Viveiros K. Redd W.D. Zhou J.C. McCarty T.R. Bazarbashi A.N. et al.Impact of chronic liver disease on outcomes of hospitalized patients with COVID-19: A multicentre United States experience., 4Shah P. Owens J. Franklin J. Mehta A. Heymann W. Sewell W. et al.Demographics, comorbidities and outcomes in hospitalized Covid-19 patients in rural southwest Georgia., 5Arshad S. Kilgore P. Chaudhry Z.S. Jacobsen G. Wang D.D. Huitsing K. et al.Treatment with hydroxychloroquine, azithromycin, and combination in patients hospitalized with COVID-19.] published before August 10, 2020 were not included. To our knowledge, a considerable number of emerging studies on this topic have been reported since Huang et al’ study was published online. Therefore, the association between obesity and COVID-19 mortality is needed to be clarified by a meta-analysis based on updated data.This meta-analysis was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement [[6]Moher D. Liberati A. Tetzlaff J. Altman D.G. Group P Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.]. We performed a comprehensive literature search in PubMed, Web of Science and EMBASE to identify all potential studies published between January 1, 2020 and June 7, 2021. The keywords were used: “COVID-19” or “SARS-CoV-2” or “coronavirus disease 2019” and “obesity” or “obese” or “body mass index” and “mortality” or “death” or “deceased”. We included studies investigating the association between obesity and COVID-19 mortality by multivariable analyses. Preprint, reviews, duplicates, errata comments, and studies with crude effect sizes were excluded.The statistical analyses were done using R software (Version 3.6.3) [[7]Balduzzi S. Rucker G. Schwarzer G. How to perform a meta-analysis with R: a practical tutorial.]. The pooled effect size and 95% CI were estimated by a random-effects model [[8]Meta-analysis in clinical trials revisited.,[9]

Wang Y, Feng R, Xu J, Hou H, Feng H, Yang H. An updated meta-analysis on the association between tuberculosis and COVID-19 severity and mortality. Journal of medical virology. 2021;DOI: 10.1002/jmv.27119.

]. I2 statistic and Cochran’s Q test were applied to evaluate heterogeneity [10Higgins J.P. Thompson S.G. Deeks J.J. Altman D.G. Measuring inconsistency in meta-analyses., 11

Yang H, Xu J, Shi L, Duan G, Wang Y. Correspondence on 'Prevalence and clinical outcomes of COVID-19 in patients with autoimmune diseases: a systematic review and meta-analysis'. Annals of the rheumatic diseases. 2021;DOI: 10.1136/annrheumdis-2020-219821.

, 12

Xu J, Xiao W, Shi L, Wang Y, Yang H. Is Cancer an Independent Risk Factor for Fatal Outcomes of Coronavirus Disease 2019 Patients? Archives of medical research. 2021;DOI: 10.1016/j.arcmed.2021.05.003:2670.

]. Begg’s test was used to assess publication bias [[13]Operating characteristics of a rank correlation test for publication bias.]. Leave-one-out sensitivity analysis was performed to assess the stability of the results [[14]

Kang X, Dong L, Yang T, Wang Z, Huang G, Chen X. Clinical and radiographic outcomes of upper thoracic versus lower thoracic upper instrumented vertebrae for adult scoliosis: a meta-analysis. Brazilian journal of medical and biological research = Revista brasileira de pesquisas medicas e biologicas. 2018;51:e6651.

,[15]

Hou H, Li Y, Zhang P, Wu J, Shi L, Xu J, et al. Smoking is independently associated with an increased risk for COVID-19 mortality: A systematic review and meta-analysis based on adjusted effect estimates. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco. 2021;DOI: 10.1093/ntr/ntab112.

]. P The main characteristics of the included studies are summarized in Table 1. A total of 138 studies with 3,863,516 cases were included. Our results demonstrated COVID-19 patients with obesity had a significantly higher risk for mortality compared to those without obesity (pooled effect size = 1.29, 95% CI: 1.24-1.35; Figure 1A ). Sensitivity analysis revealed our results were stable (Figure 1B). Consistent findings were observed in the subgroup analyses by sample size, age, male percentage and setting. Begg’s test indicated there was no potential publication bias (P = 0.331).

Table 1General information of the included studies

Note: The age (years) was expressed as mean ± standard deviation (SD) and median (interquartile range, IQR). BMI, body mass index; CI, confidence interval; NA, not available; UK, United Kingdom; USA, the United States of America. * indicates the combined effect size and 95% CI were used.

Figure 1(A) The forest plot demonstrated the significant relationship between obesity and the increased risk for mortality among patients with coronavirus disease 2019 (COVID-19) on the basis of 138 eligible studies with 3,863,516 cases reporting adjusted effect estimates and (B) Leave-one-out sensitivity analysis indicated that our results were stable and robust.

Several limitations existed in this meta-analysis. First, most of the included studies were from Americas and Europe, thus the findings should be explained with caution in other regions (such as Asia and Africa). Second, although the pooled effect size was estimated on the basis of adjusted effect sizes, the adjusted factors are not fully consistent among the included studies. Third, most of the enrolled studies are retrospective studies, thus further meta-analysis with more prospective studies should be performed to verify our results.

In conclusion, this updated meta-analysis demonstrated obesity was significantly associated with an increased risk for COVID-19 mortality. We hope the updated findings will contribute to more accurate elaboration and substantiation of the data reported by Huang et al [[1]Huang Y. Lu Y. Huang Y.M. Wang M. Ling W. Sui Y. et al.Obesity in patients with COVID-19: a systematic review and meta-analysis.].ReferencesHuang Y. Lu Y. Huang Y.M. Wang M. Ling W. Sui Y. et al.

Obesity in patients with COVID-19: a systematic review and meta-analysis.

Metabolism: clinical and experimental. 113: 154378Deiana G. Azara A. Dettori M. Delogu F. Vargiu G. Gessa I. et al.

Deaths in SARS-Cov-2 Positive Patients in Italy: The Influence of Underlying Health Conditions on Lethality.

International journal of environmental research and public health. 17: 4450Hashemi N. Viveiros K. Redd W.D. Zhou J.C. McCarty T.R. Bazarbashi A.N. et al.

Impact of chronic liver disease on outcomes of hospitalized patients with COVID-19: A multicentre United States experience.

Liver international : official journal of the International Association for the Study of the Liver. 40: 2515-2521Shah P. Owens J. Franklin J. Mehta A. Heymann W. Sewell W. et al.

Demographics, comorbidities and outcomes in hospitalized Covid-19 patients in rural southwest Georgia.

Annals of medicine. 52: 354-360Arshad S. Kilgore P. Chaudhry Z.S. Jacobsen G. Wang D.D. Huitsing K. et al.

Treatment with hydroxychloroquine, azithromycin, and combination in patients hospitalized with COVID-19.

International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases. 97: 396-403Moher D. Liberati A. Tetzlaff J. Altman D.G. Group P

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.

Annals of internal medicine. 151 (): 264-269Balduzzi S. Rucker G. Schwarzer G.

How to perform a meta-analysis with R: a practical tutorial.

Evidence-based mental health. 22: 153-160

Meta-analysis in clinical trials revisited.

Contemporary clinical trials. 45: 139-145

Wang Y, Feng R, Xu J, Hou H, Feng H, Yang H. An updated meta-analysis on the association between tuberculosis and COVID-19 severity and mortality. Journal of medical virology. 2021;DOI: 10.1002/jmv.27119.

Higgins J.P. Thompson S.G. Deeks J.J. Altman D.G.

Measuring inconsistency in meta-analyses.

Bmj. 327: 557-560

Yang H, Xu J, Shi L, Duan G, Wang Y. Correspondence on 'Prevalence and clinical outcomes of COVID-19 in patients with autoimmune diseases: a systematic review and meta-analysis'. Annals of the rheumatic diseases. 2021;DOI: 10.1136/annrheumdis-2020-219821.

Xu J, Xiao W, Shi L, Wang Y, Yang H. Is Cancer an Independent Risk Factor for Fatal Outcomes of Coronavirus Disease 2019 Patients? Archives of medical research. 2021;DOI: 10.1016/j.arcmed.2021.05.003:2670.

Operating characteristics of a rank correlation test for publication bias.

Biometrics. 50: 1088-1101

Kang X, Dong L, Yang T, Wang Z, Huang G, Chen X. Clinical and radiographic outcomes of upper thoracic versus lower thoracic upper instrumented vertebrae for adult scoliosis: a meta-analysis. Brazilian journal of medical and biological research = Revista brasileira de pesquisas medicas e biologicas. 2018;51:e6651.

Hou H, Li Y, Zhang P, Wu J, Shi L, Xu J, et al. Smoking is independently associated with an increased risk for COVID-19 mortality: A systematic review and meta-analysis based on adjusted effect estimates. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco. 2021;DOI: 10.1093/ntr/ntab112.

Article InfoPublication History

Accepted: June 17, 2021

Received: June 9, 2021

Publication stageIn Press Journal Pre-ProofFootnotes

☆Funding: This study was supported by grants from the National Natural Science Foundation of China (No. 81973105), Key Scientific Research Project of Henan Institution of Higher Education (No. 21A330008), and Joint Construction Project of Henan Medical Science and Technology Research Plan (No. LHGJ20190679). The funders have no role in the data collection, data analysis, preparation of manuscript and decision to submission.

☆☆Author contributions: Yadong Wang, Haiyan Yang and Huifen Feng conceptualized the study. Hongjie Hou, Jie Xu and Yadong Wang performed literature search and data extraction. Jie Xu, Ying Wang, Huifen Feng and Haiyan Yang analyzed the data. Yadong Wang wrote the manuscript. All the authors approved the final manuscript.

Identification

DOI: https://doi.org/10.1016/j.metabol.2021.154820

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