The Washington PostDemocracy Dies in Darkness

The Health 202: Obese Americans suffer disproportionately from the coronavirus

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with Paige Winfield Cunningham

The obesity epidemic has made it harder for the United States to fight the coronavirus pandemic.

And the pandemic has made it harder for Americans to fight obesity.

Weight loss is top of mind for many people in January, when nearly 40 percent of people who make a resolution say they plan to lose weight. But this year, as the United States continues its struggle against the virus, the nation’s record obesity rate feels particularly dire. Obese people have died of covid-19 at disproportionate rates. For a time, hospitals suspended bariatric surgeries ― one of the best ways of helping obese people keep  off weight.

And coronavirus vaccines might not be as effective in people who are obese.

As if the country needed yet another obstacle to getting the population immunized, researchers are concerned the vaccines might not provide obese individuals with as much protection as those who aren't overweight.

There’s no research on this question yet, but vaccines against the seasonal flu, hepatitis B and rabies have prompted reduced responses in obese people compared to leaner ones. If that’s true for the coronavirus vaccine, it would bode poorly for U.S. ability to mount a successful vaccination effort, considering a record 42 percent of Americans now meet the obesity threshold.

Dr. Rajat Madan, a professor of medicine specializing in infectious diseases at the University of Cincinnati Medical Center pointed out results from the Pfizer vaccine trial found similar results in vaccine efficacy between obese and non-obese populations. But it might be possible obese people will see their immunity wane faster or will need an extra booster shot. 

“Obese individuals have a dysregulated immune response. In that sense, one would think that covid-19 vaccines may have less efficacy,” Madan said. 

The stakes are higher than normal for obese Americans, who are more likely to become severely ill with covid-19 or die of it. Researchers have found having obesity already increases one’s likelihood of hospitalization for covid-19 by 113 percent and chances of dying of the illness by 48 percent.

The pandemic has only made it harder to sustain weight loss for those who are obese.

Hospitals all over the country have suspended bariatric surgeries along with other elective procedures during the pandemic, both to save ICU space and to protect postoperative patients from infection. Yet bariatric surgery may be one of the most potent weapons for fighting obesity.

Studies show it’s really, really hard to lose weight and keep it off. One study from U.K. researchers found an obese woman has 1 in 124 odds of returning to a normal weight, while for an obese man the odds are 1 in 210 over a nine-year period.

There’s one major exception: Some 70 percent of patients receiving one method of bariatric surgery maintained at least a 20 percent weight loss 10 years later. Such surgery has been found to reduce cardiovascular risk factors and even result in remission of Type 2 diabetes.

Evidence for its efficacy keeps piling up: A study published last year in the Annals of Internal Medicine found bariatric surgery was effective in helping patients lower blood pressure and control hypertension after three years.

About 93 million Americans are classified as obese, meaning they have a body mass index over 30. Of those, the American Society for Metabolic and Bariatric Surgery (ASMBS) estimates roughly 24 million have severe obesity — defined as a BMI over 40 or over 35 with another health problem such as diabetes, sleep apnea or high blood pressure — which could potentially qualify them for weight-loss surgery.

Fewer than 1 percent of people who meet the criteria for bariatric surgery get the procedure.

While bariatric surgery has become increasingly less invasive in recent years and is considered fairly safe, it isn’t without discomfort and risks. Changes to the gastrointestinal tract seem to make it harder to absorb micronutrients, for instance, leaving some patients susceptible to serious complications without daily vitamin supplements. 

But Deepak Bhatt, the director of interventional cardiovascular programs at Brigham and Women’s Health who has spent years researching outcomes in bariatric surgery, said there’s another reason so few patients get the procedure: stigma from both doctors and patients.

“There are two issues in terms of widespread physician, and maybe even patient perception,” Bhatt said. “One is that bariatric surgery is for cosmetic reasons … and the second is the perception that obesity is a problem with willpower and if it only people had better willpower it would go away.”

One survey of U.S. adults found about 40 percent believed weight-loss surgery was the “easy way out.”

But difficulty with weight loss isn’t just about people not trying hard enough.

Part of the reason it’s so hard to maintain weight loss is because the body fights back: Losing weight triggers a slowdown in people’s metabolism at the same time hormones ramp up hunger signals. This means someone who has lost weight probably will need to eat less, even as they feel hungrier, to maintain the same weight as someone else who never had the extra pounds to start with.

Over the past decade, insurance coverage for bariatric surgery has improved dramatically, but it hasn't always been accompanied by a major uptake in the surgery.

As professional guidelines have been updated to reflect the efficacy of bariatric surgery, more insurance companies have expanded coverage. As of 2018, Medicare, 49 state Medicaid programs and most commercial insurers offered coverage for at least one bariatric procedure.

“But expanding insurance coverage alone does not necessarily mean that patients get greater access,” said Hamlet Gasoyan, a researcher at Temple University. “The devil is in the details.”

Many plans require that a patient first go through half a year of preoperative counseling, which can be costly. Meanwhile, patients are often on the hook to pay thousands of dollars with no guarantee the plan will foot any necessary follow-up procedures.

Gasoyan argues changing insurance coverage is feasible and provides medical benefits over the long run, and cites the case of MGM Resorts International. The hospitality company, which runs its own benefits program, found good clinical outcomes after offering an incentive for its employees who underwent weight-loss surgery: $5,000 in reimbursed co-pays after two years and another $5,000 to cover procedures such as excess skin removal after four years.

Ahh, oof and ouch

AHH: Democrat are inching closer to control of the Senate with a victory for Warnock.

Democrat Raphael Warnock won a historic upset in a runoff election against incumbent Republican Sen. Kelly Loeffler (R), becoming the first African American Democratic senator from a former Confederate state. Democrat Jon Ossoff, meanwhile, holds a narrow lead over Republican David Perdue, although the race was too close to call as of this morning.

If Ossoff wins, the Senate will be split 50-50 between the two major parties, but Democrats would control the majority with Vice President-elect Kamala D. Harris casting the tie-breaking vote. In rare moments in the past when control of the chamber was evenly split, parties have agreed to some sharing of power, but it’s unclear if such an agreement would succeed in current polarized environment.

Control of the chamber would allow Democrats to confirm Biden’s nominations for Cabinet positions and federal judgeships.

But even if the Democrats win both Georgia seats, passing ambitious health-care legislation may be an uphill battle. Most legislation will still be subject to filibuster rules, which require 60 votes. Democrats best hope may be to push some legislation through the budget reconciliation process, which requires a simple majority.

OOF: Los Angeles hospitals are running out of oxygen and turning patients away.

“Los Angeles County has been so overwhelmed it is running out of oxygen, with ambulance crews instructed to use oxygen only for their worst-case patients. Crews were told not to bring patients to the hospital if they have little hope of survival and to treat and declare such patients dead on the scene to preserve hospital capacity. Several Los Angeles hospitals have turned away ambulance traffic in recent days because they can’t provide the air flow needed to treat patients,” The Washington Post’s Fenit Nirappil and William Wan report.

“We’re no longer a wave or surge or surge upon a surge. We really are in the middle of a viral tsunami,” Robert Kim-Farley, a medical epidemiologist at the UCLA Fielding School of Public Health, told The Post.

A record 131,000 covid-19 patients are hospitalized nationwide, even as vaccine rollout is off to a slow start. Public health experts worry holiday travel could make the situation worse: Someone exposed to the virus on Christmas may have been contagious by the time they attended New Year’s eve festivities or traveled home.  

In Arizona, 69 out of every 100,000 residents are now hospitalized with the virus, while in Atlanta nearly every major hospital in the metropolitan area is now full. In some cases, patients are being treated inside ambulances or in refurbished gyms. 

“Public health experts say the country faces a similar challenge it did last spring: buying time. In the early months of the pandemic, authorities urged the public to ‘flatten the curve’ by following stay-at-home orders to give hospitals time to expand their capacity and protect their staff. They are pleading with Americans to keep following basic precautions — wearing masks, socially distancing, avoiding crowds — with the promise of a vaccine on the horizon,” Fenit and William write.

OUCH: States are scrambling to deploy coronavirus vaccines.

The Trump administration has largely punted responsibility for vaccine administration to the state, but it's not clear whether states' efforts will be enough. So far states have administered roughly 4.8 million of the approximately 17 million doses shipped out by the federal government. 

“The patchwork of responses comes as desperate governors are facing a vacuum of federal support, along with dire funding and workforce shortages that are hampering the pace of the rollout,” Politico’s Rachel Roubein, Brianna Ehley and Sarah Owermohle report. “Though Trump administration officials predict vaccination rates will pick up this week, the White House's coronavirus task force has not convened a call with governors since Dec. 21. States have not yet seen the nearly $9 billion Congress approved to help vaccine distribution in a late December relief package.”

Federal officials also seem divided over strategies to stretch the vaccine supply further. After Operation Warp Speed chief Moncef Slaoui said the government was in talks with Moderna to halve doses of its shots for many adults, a Food and Drug Administration statement rebuked the notion, saying such changes were unsupported by the science.

Some states are turning to drastic measures. New York Gov. Andrew Cuomo (D) threatened to fine hospitals that did not use up all of their coronavirus supplies this week, while other states are calling in retired health-care workers and even veterinarians to staff vaccine sites.

Who gets the vaccine

A nursing home in Florida gave vaccines to wealthy donors.

MorseLife Health System, a high-end nursing home and assisted-living facility in West Palm Beach, Fla., gave vaccines not only to its residents and staff but also to people who made large donations to the facility, including members of the Palm Beach Country Club, The Post’s Isaac Stanley-Becker and Shawn Boburg report. The arrangement may have violated national immunization guidelines and state protocols, although some officials say that the rules have not been clear enough.

“The episode highlights how the country’s patchwork approach to immunization against the coronavirus — leaving decisions about eligibility to state and local authorities as well as to individual providers — is creating opportunities for facilities to provide access to well-connected people while thousands of others wait in line,” Isaac and Shawn write.

Some individuals involved with the vaccination campaign have said that the doses were only given to people who fell under the state’s broad priority groups for vaccination, including individuals over 65.

But state Rep. Omari Hardy (D), who represents the section of West Palm Beach that includes MorseLife, said the facility appeared to be “selling access” and was taking advantage of a process not available to other elderly people in the county.

Elsewhere in healthcare

Hospital prices just became much more transparent.

“Hospitals face the new year with new requirements to post price information they have long sought to obscure: the actual prices negotiated with insurers and the discounts they offer their cash-paying customers,” Kaiser Health News’s Julie Appleby reports. “The move is part of a larger push by the Trump administration to use price transparency to curtail prices and create better-informed consumers.”

The information could be of particular interest to the uninsured and Americans with high-deductible plans who may shop for the best prices. Employers meanwhile may provide incentives to encourage people to use the lowest-cost facilities.  

But there’s some disagreement over whether the rule will succeed in driving down prices. While revealing negotiated prices could cause some more expensive hospitals to reduce prices when they bargain with insurers or employers, lower-cost hospitals might demand more money. And a dominant hospital with a lot of a market power in a particular region may be able to continue demanding high prices, if employers feel like they can’t afford to cut it out of their networks.

The hospital industry has tried to sue to block the rules, but has so far been unsuccessful. 

Sugar rush