Intellectual disability is second only to old age as a risk factor for COVID-19 death, and obesity is linked to coronavirus-related hospitalization and death, two new studies find.
Deadlier than heart, kidney, lung disease
The first study, led by researchers from Jefferson Health in Philadelphia and published late last week as a commentary in the New England Journal of Medicine Catalyst, involved analyzing the medical records of 558,672 US COVID-19 patients from January 2019 to November 2020.
Patients with intellectual disabilities had higher rates of coronavirus infection than those without those limitations (3.1% vs 0.9%). In unadjusted analysis, compared with the 431,669 patients without intellectual disabilities, the 127,003 patients with intellectual disabilities were more susceptible to hospitalization (63.1% vs. 29.1%), intensive care unit (ICU) admission (14.5% vs. 6.3%), and death (8.2% vs. 3.8%).
Intellectual impairments were the strongest predictor of death other than older age. “The chances of dying from COVID-19 are higher for those with intellectual disability than they are for people with congestive heart failure, kidney disease or lung disease,” lead study author Jonathan Gleason, MD, said in a Thomas Jefferson University news release.
COVID-19 patients with intellectual disabilities were more likely to be established patients of the health system where they sought care; 22% were new patients, compared with 44% of those without intellectual disabilities. They were also more likely to be younger than those without these limitations, with only 1% older than 80 years and 18% aged 60 to 80, versus 5% and 25%, respectively.
Forty-four percent of patients with intellectual disabilities had insurance coverage associated with low incomes, versus 28% in other patients. They also had higher rates of all underlying medical conditions except cancer. “The risks to patients with intellectual disabilities incorporate not only risks associated with intellectual disability itself, but also the risks associated with these comorbidities that were overrepresented among those with intellectual disabilities,” the authors wrote.
A ‘devastating impact’ on disabled
The adjusted odds ratio (OR) for COVID-19 infection in patients with intellectual disabilities compared with those without was 2.6, while the OR was 2.7 for hospitalization and 1.3 for in-hospital death. At 1.0, the OR for ICU stay was not statistically significant. “This raises questions about whether critically ill patients with intellectual disabilities are less likely to be transferred to a higher level of care, or if this reflects differences in advanced care planning in this population,” the investigators wrote. “Further study is needed in this area.”
The researchers noted several factors that may explain the increased risk of infection in people with cognitive impairments, including the need for daily care and its attendant close contact with care providers, less ability to comply with public health recommendations, use of shared transportation, residence in long-term care facilities, and sensory issues that interfere with mask wearing for long periods.
“Covid-19 has had a devastating impact on individuals with intellectual disabilities,” the authors wrote. “Beyond the direct risk of Covid-19, the pandemic has had negative effects on the ability of individuals with intellectual disabilities to receive the health care and daily support that they typically receive.”
They called for more resources to vaccinate this population and their care providers, provision of healthcare outcome tracking for these patients, and a redesign of the care model in light of their unique needs.
Dose-response relationship with weight
In the second study, published today in Morbidity and Mortality Weekly Report, researchers from the US Centers for Disease Control and Prevention analyzed data from 148,494 adult COVID-19 patients seen in the emergency department or admitted to 238 hospitals that reported height and weight from March to December 2020.
They identified a nonlinear relationship between body mass index (BMI) and coronavirus severity, with the lowest risks observed in patients with a BMI between healthy weight (18.5 to 24.9 kg/m2) and overweight (25 to 29.9 kg/m2), and rising risks found among those with higher BMIs. The risk for hospitalization, ICU admission, and death were lowest at BMI 24.2, 25.9, and 23.7 kg/m2, respectively, and then rose dramatically with higher BMIs.
Overweight and obesity (30 to 45 kg/m2 or higher) were risk factors for invasive mechanical ventilation (adjusted rate ratios [aRRs], 1.12 for BMI 25 to 29.9 kg/m2 to 2.08 for BMI 45 kg/m2 or higher).
Compared with patients with normal BMIs, obesity increased the risk of hospitalization (aRR, 1.07 for BMI 30 to 34.9 kg/m2 to 1.33 for BMI 45 kg/m2 or higher) and death (aRR, 1.08 for BMI 30 to 34.9 kg/m2 to 1.61 for higher), especially for those younger than 65 years. Patients with BMI 40 to 44.9 kg/m2 had an aRR of 1.06 for ICU admission, and those with higher BMIs had an aRR of 1.16.
Underweight patients (BMI, 18.5 kg/m2 or lower) were at a 20% higher risk of hospitalization than their healthy-weight counterparts. While underweight patients younger than 65 were at 41% higher risk for hospitalization, those aged 65 and older were at a 7% increased risk.
The results highlight the need to prevent COVID-19 infection in adults with high BMIs and their close contacts through the wearing of face coverings, continued vaccine prioritization, and outreach, the researchers wrote.
“The findings in this report highlight a dose-response relationship between higher BMI and severe COVID-19–associated illness and underscore the need for progressively intensive illness management as obesity severity increases,” the authors concluded. “Continued strategies are needed to ensure community access to nutrition and physical activity opportunities that promote and support a healthy BMI.”