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. 2022 Apr 7;17(4):e0265473. doi: 10.1371/journal.pone.0265473

How useful are body mass index and history of diabetes in COVID-19 risk stratification?

Sarah-Jeanne Salvy 1,*,#, Geetanjali D Datta 1,#, Qihan Yu 1, Marie Lauzon 2, Shehnaz K Hussain 3, Susan Cheng 4, Joseph E Ebinger 5, Mark O Goodarzi 6, Jane C Figueiredo 1
Editor: Fernando A Wilson7
PMCID: PMC8989225  PMID: 35390025

Abstract

Objective

This study examines the value of risk stratification by documented diagnosis of diabetes and objectively measured height and weight (BMI) in COVID-19 severity and mortality in a large sample of patients in an urban hospital located in Southern California.

Methods

Data from a retrospective cohort study of COVID-19 patients treated at Cedars-Sinai Medical Center between March 8, 2020, and January 25, 2021, was analyzed. Sociodemographic characteristics and pre-existing conditions were extracted from electronic medical records. Univariable and multivariable logistic regression models identified associated risk factors, and a regression causal mediation analysis examined the role of diabetes in the association between obesity and illness severity. All analyses were stratified by age (<65 and ≥65).

Results

Among individuals <65yo, diabetes accounted for 19–30% of the associations between obesity and COVID-19 illness severity. Among patients ≥65yo, having a BMI <18.5 was a risk factor for mortality regardless of diabetes history.

Conclusion

Our findings have clinical implications in documenting which patients may be at elevated risk for adverse outcomes. More in-depth prospective studies are needed to capture how glycemic regulation may influence prognosis.

Introduction

Since the onset of the global COVID-19 pandemic, elucidating risk factors of disease severity and mortality have become of primary importance to the medical and public health communities. Several reports have suggested that obesity is associated with COVID-19 progression [1–12], yet it is not entirely clear whether the association between obesity and adverse outcomes is due to excess weight per se [11, 13–17], or whether other metabolic conditions oft-associated with obesity are driving these relationships [18–20]. Outside the context of COVID-19, obesity in absence of metabolic abnormalities is not associated with higher risk for all-cause mortality; whereas elevation of even a single metabolic risk factor is associated with increased mortality risk [21]. While emerging studies do support the implication of metabolic and biomarker profiles in COVID-19 severity and such work contributes to our understanding of the mechanisms of disease progression, scientific pursuits and in-depth considerations of cardiometabolic parameters may not be feasible for front-line workers in the context of high-volume critical care for COVID-19 patients. With the constant emergence of new variants and increase in case rates in many locations, already fatigued clinical staff may benefit from heuristics guided by assessment of patient body mass index (BMI) or prior diagnoses of diabetes to guide risk stratification. Utilizing such readily accessible parameters may ease burdens and enable clinical staff to make critical decisions in the face of uncertainty.

Therefore, this study examines the value of risk stratification by BMI and documented diagnosis of diabetes in COVID-19 severity and mortality in a large sample of patients in an urban hospital located in Southern California. Based on previous reports indicating stronger associations between weight, cardiometabolic profiles and COVID-19 severity in younger patients [5–7], and given that age is a significant predictor of mortality [22], all analyses were stratified by age following definitions used in similar studies and health services research [23].

Materials and methods

Study sample

The Cedars-Sinai Health System (CSHS) is located in Los Angeles, California with a catchment area of 1·8 million individuals and includes Cedars-Sinai Medical Center (CSMC), Marina Del Rey Hospital (MDRH), and affiliated clinics. In the present study, we included all CSHS patients (1) who received a confirmed diagnosis of COVID-19 infection while being evaluated or treated for suspected COVID-19 between March 8, 2020 and January 25, 2021 and (2) who had objective height and weight measurements and a documented diagnosis of diabetes in their medical record. COVID-19 infection was evaluated using reverse transcriptase polymerase chain reaction of extracted RNA from nasopharyngeal swabs. Until March 21, 2020, patient testing was performed by the Los Angeles Department of Public Health, after which the CSMC Department of Pathology and Laboratory Medicine used the A*STAR FORTITUDE KIT 2·0 COVID-19 Real-Time RT- PCR Test (Accelerate Technologies Pte Ltd, Singapore). For the 3·6% of patients who had COVID-19 testing performed at an outside facility, documentation of a positive test was carefully reviewed by medical staff. Quality control and assurance analyses on data extracted directly from the electronic health record (EHR) were conducted and manual chart review was used to verify collected data where appropriate. Patients provided electronic informed consent via the secure, HIPAA- compliant data capturing tool, REDCap [24, 25]. The CSMC institutional review board approved all protocols for the current study (Proposal # Pro00056865).

Measurements: Exposures, outcomes and covariates

Demographics

Race was self-reported in the EHR as White, African American/Black, Asian, other, and unknown. Ethnicity was self-reported in the EHR and was categorized as Hispanic, non-Hispanic, and unknown. We created a variable combining race and ethnicity into five categories (e.g., Non-Hispanic Black) for use in the statistical models. The participants’ zip-codes were linked to census data to provide a measure of area-level income. The low-income category was defined based on zip-code with a median household income below 200% of the federal poverty line. In the absence of other available measures, zip-code level median income was used with the knowledge that caution should be used in its interpretation.

Smoking status

Smoking history was ascertained via self-report in the EHR and was categorized as never, current, former, or unknown/not asked.

Body mass index (BMI)

BMI was calculated from patients’ last known objectively assessed height and weight recorded in their EHR, which could have been either prior to- or after COVID-19 diagnoses. To categorize patients based on their calculated BMI, we used the criteria outlined by the World Health Organization, such that: underweight (<18·5 kg/m2), normal weight (18·5 to 24·9 kg/m2), overweight (25·0 to 29·9 kg/m2), and obesity (≥30·0 kg/m2). Consistent with other studies assessing the relationships between weight status and COVID-19, we used normal weight as the reference group.

Diabetes

Patients’ history of diabetes was coded using the Charlson comorbidity score based on ICD codes documented in the medical record [26].

Illness severity

Illness severity was defined in four categories: 1) no hospital admission, 2) requiring any kind of hospital admission, 3) requiring intensive care during hospitalization, and 4) requiring intubation and mechanical ventilation or death. Admission to an intensive care unit (ICU) was identified via time stamps recorded for admission, unit transfers, and discharge. Interventions such as intubation were identified through time stamped orders in the EHR and verified by manual chart review.

Mortality

Death was ascertained from time stamps recorded for admission, unit transfers, and discharge.

Analytic plan

Descriptive analyses were used to assess the distribution of patient demographics and clinical characteristics by mortality status. Median (interquartile range [IQR]) was used to summarize continuous measures, while categorical variables were summarized as counts and percentages. We used Pearson’s chi-square test to evaluate statistical differences between patients who were deceased or alive for categorical variables. Bivariate comparisons for continuous variables were evaluated using the Student t-test or Wilcoxon rank sum test. Potential risk factors associated with mortality were identified using univariable and multivariable logistic regression models. Potential risk factors associated with COVID-19 severity were determined using univariable and multivariable ordered logistic regression. Cumulative risk was derived from statistical models including both BMI and diabetes variables with results presented in forest plots.

Because we hypothesized diabetes as a potential mediator on the pathway between obesity and disease outcomes, diabetes was included in the univariate analyses, but not in the multivariable models. The independent contributions of diabetes are however included in the forest plots. We performed regression-based causal mediation analyses to examine the degree to which diabetes mediates the relationship between obesity and our outcomes of interest where one was observed. Causal mediation analysis was conducted using the mediation package in R [27]. The mediate function and 1,000 bootstrap simulations were used to estimate the proportion mediated, and their respective 95% CIs, adjusting for age and sex to account for potential confounders. A proportion mediated equal or greater than 10% was considered clinically relevant for mortality and severity.

Furthermore, given that age is a significant predictor of mortality, all analyses were stratified by age (<65 and ≥65). The cut-point of 65 years was selected based on definitions used in similar studies and health services research [23]. Analyses were performed using SAS software, version 9·4 (SAS Institute) and R software, version 4·0·3 (R Foundation, Vienna, Austria) with two-sided tests and a significance level of 0·05. The Bonferroni-Holm correction was used to adjust p-values for multiple comparisons.

Results

Patient characteristics

In our cohort, 2458 participants were younger than 65 years and 1766 participants were over the age of 65 (Table 1). Mortality in the younger age group was 17·4% (308/1766) and in the older age group was 2·2% (55/2458). Over 40% of individuals over the age of 65 had a history of diabetes and 25% had a BMI >30, while among those younger than 65 years of age approximately 21% had a history of diabetes and 43% had a BMI>30.

Table 1. Characteristics of patients with objective BMI data, stratified by age.

<65 ≥65
Alive (N = 2403) Dead (N = 55) Total (N = 2458) p-value Alive (N = 1458) Dead (N = 308) Total (N = 1766) p-value
Sex ·· ·· ·· 0.0004 ·· ·· ·· 0.11
    Female 1173 (98.9%) 13 (1.1%) 1186 (48.3%) ·· 726 (84.0%) 138 (16.0%) 864 (48.9%) ··
    Male 1230 (96.7%) 42 (3.3%) 1272 (51.7%) ·· 732 (81.2%) 170 (18.8%) 902 (51.1%) ··
Ethnicity ·· ·· ·· 0.19 ·· ·· ·· 0.044
    Non-Hispanic 1333 (98.2%) 24 (1.8%) 1357 (55.2%) ·· 1131 (83.1%) 230 (16.9%) 1361 (77.1%) ··
    Hispanic 959 (97.3%) 27 (2.7%) 986 (40.1%) ·· 299 (82.4%) 64 (17.6%) 363 (20.6%) ··
    Unknown 111 (96.5%) 4 (3.5%) 115 (4.7%) ·· 28 (66.7%) 14 (33.3%) 42 (2.4%) ··
Race ·· ·· ·· 0.29 ·· ·· ·· 0.0046
    White 1367 (97.4%) 36 (2.6%) 1403 (57.1%) ·· 955 (83.4%) 190 (16.6%) 1145 (64.8%) ··
    African American/Black 399 (97.3%) 11 (2.7%) 410 (16.7%) ·· 272 (84.7%) 49 (15.3%) 321 (18.2%) ··
    Asian 182 (98.9%) 2 (1.1%) 184 (7.5%) ·· 83 (72.8%) 31 (27.2%) 114 (6.5%) ··
    Other 332 (99.1%) 3 (0.9%) 335 (13.6%) ·· 123 (83.1%) 25 (16.9%) 148 (8.4%) ··
    Unknown 123 (97.6%) 3 (2.4%) 126 (5.1%) ·· 25 (65.8%) 13 (34.2%) 38 (2.2%) ··
Diabetes ·· ·· ·· <0.0001 ·· ·· ·· 0.010
    No 1914 (98.4%) 31 (1.6%) 1945 (79.1%) ·· 873 (84.5%) 160 (15.5%) 1033 (58.5%) ··
    Yes 489 (95.3%) 24 (4.7%) 513 (20.9%) ·· 585 (79.8%) 148 (20.2%) 733 (41.5%) ··
BMI (calculated) ·· ·· ·· 0.027 ·· ·· ·· <0.0001
    N 2403 55 2458 ·· 1458 308 1766 ··
    Mean (SD) 29.6 (7.5) 32.1 (8.6) 29.7 (7.5) ·· 28.6 (66.2) 25.0 (6.3) 28.0 (60.3) ··
    Median 28.8 32.1 28.8 ·· 26.2 24.2 26.0 ··
    Q1, Q3 24.7, 33.6 26.3, 37.1 24.7, 33.7 ·· 22.8, 30.3 20.4, 29.0 22.2, 30.1 ··
    Range (11.9–74.1) (18.9–59.5) (11.9–74.1) ·· (14.0–2541.7) (11.4–56.6) (11.4–2541.7) ··
BMI category ·· ·· ·· 0.13 ·· ·· ·· <0.0001
    Underweight 80 (100.0%) 0 (0.0%) 80 (3.3%) ·· 91 (68.9%) 41 (31.1%) 132 (7.5%) ··
    Normal weight 554 (97.9%) 12 (2.1%) 566 (23.0%) ·· 519 (80.5%) 126 (19.5%) 645 (36.5%) ··
    Overweight 741 (98.4%) 12 (1.6%) 753 (30.6%) ·· 466 (86.0%) 76 (14.0%) 542 (30.7%) ··
    Obesity 1028 (97.1%) 31 (2.9%) 1059 (43.1%) ·· 382 (85.5%) 65 (14.5%) 447 (25.3%) ··
Myocardial infarction (Charlson) ·· ·· ·· <0.0001 ·· ·· ·· <0.0001
    No 2289 (98.4%) 38 (1.6%) 2327 (94.7%) ·· 1212 (85.2%) 211 (14.8%) 1423 (80.6%) ··
    Yes 114 (87.0%) 17 (13.0%) 131 (5.3%) ·· 246 (71.7%) 97 (28.3%) 343 (19.4%) ··
Congestive heart failure ·· ·· ·· <0.0001 ·· ·· ·· <0.0001
    No 2201 (98.5%) 33 (1.5%) 2234 (90.9%) ·· 1039 (85.2%) 180 (14.8%) 1219 (69.0%) ··
    Yes 202 (90.2%) 22 (9.8%) 224 (9.1%) ·· 419 (76.6%) 128 (23.4%) 547 (31.0%) ··
Chronic pulmonary disease ·· ·· ·· 1.00 ·· ·· ·· 1.00
    No 2034 (97.8%) 46 (2.2%) 2080 (84.6%) ·· 1089 (82.9%) 225 (17.1%) 1314 (74.4%) ··
    Yes 369 (97.6%) 9 (2.4%) 378 (15.4%) ·· 369 (81.6%) 83 (18.4%) 452 (25.6%) ··
Chronic pulmonary disease (Charlson) ·· ·· ·· 1.00 ·· ·· ·· 1.00
    No 2036 (97.8%) 46 (2.2%) 2082 (84.7%) ·· 1090 (82.9%) 225 (17.1%) 1315 (74.5%) ··
    Yes 367 (97.6%) 9 (2.4%) 376 (15.3%) ·· 368 (81.6%) 83 (18.4%) 451 (25.5%) ··
Admit ·· ·· ·· <0.0001 ·· ·· ·· <0.0001
    Not Admitted 1054 (99.9%) 1 (0.1%) 1055 (42.9%) ·· 216 (98.2%) 4 (1.8%) 220 (12.5%) ··
    Admitted 1349 (96.2%) 54 (3.8%) 1403 (57.1%) ·· 1242 (80.3%) 304 (19.7%) 1546 (87.5%) ··
ICU ·· ·· ·· <0.0001 ·· ·· ·· <0.0001
    No ICU 2172 (99.5%) 11 (0.5%) 2183 (88.8%) ·· 1259 (89.3%) 151 (10.7%) 1410 (79.8%) ··
    ICU 231 (84.0%) 44 (16.0%) 275 (11.2%) ·· 199 (55.9%) 157 (44.1%) 356 (20.2%) ··
Intubated ·· ·· ·· <0.0001 ·· ·· ·· <0.0001
    No 2354 (98.4%) 38 (1.6%) 2392 (97.3%) ·· 1410 (83.9%) 270 (16.1%) 1680 (95.1%) ··
    Yes 49 (74.2%) 17 (25.8%) 66 (2.7%) ·· 48 (55.8%) 38 (44.2%) 86 (4.9%) ··
Smoking status ·· ·· ·· 0.012 ·· ·· ·· 0.0002
    Current Smoker 117 (97.5%) 3 (2.5%) 120 (4.9%) ·· 765 (86.5%) 119 (13.5%) 884 (50.1%) ··
    Former Smoker 315 (97.2%) 9 (2.8%) 324 (13.2%) ·· 339 (80.3%) 83 (19.7%) 422 (23.9%) ··
    Never Smoker 1523 (98.4%) 24 (1.6%) 1547 (62.9%) ·· 321 (77.2%) 95 (22.8%) 416 (23.6%) ··
    Unknown/not asked 448 (95.9%) 19 (4.1%) 467 (19.0%) ·· 33 (75.0%) 11 (25.0%) 44 (2.5%) ··
Area-level income ·· ·· ·· 0.24 ·· ·· ·· 0.62
    Missing 23 1 24 ·· 17 2 19 ··
    Median income < 200% FPL 982 (97.2%) 28 (2.8%) 1010 (41.5%) ·· 478 (81.8%) 106 (18.2%) 584 (33.4%) ··
    Median income > = 200% FPL 1398 (98.2%) 26 (1.8%) 1424 (58.5%) ·· 963 (82.8%) 200 (17.2%) 1163 (66.6%) ··
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Models

Among those younger than 65 years of age, obesity was associated with increased disease severity relative to normal weight (OR = 1·5, 95%CI: 1·2–1·9; Table 2). Assuming proportional odds, the odds of a severity score = 3 (vs combined scores of 0, 1, 2) was 1·5 time higher among participants with obesity compared to individuals with normal weight. Among participants 65 years of age and older, male (OR = 1·4, 95%CI: 1·1–1·8) and Hispanic (vs non-Hispanic White) individuals were associated with increased odds of disease severity (OR = 1·7, 95%CI: 1·2–2·3; Table 2). Underweight (vs normal weight) was associated with increased odds (OR = 1·9, 95%CI: 1·1–3·1) of mortality.

Table 2. Logistic models stratified by outcome and age.

Ordinal logistic models for illness severity
<65 ≥65
Univariable Multivariable Univariable Multivariable
OR (95% CI) p-value OR (95% CI) p-value OR (95% CI) p-value OR (95% CI) p-value
Sex (Male vs. Female) 2.2 (1.9, 2.7) <0.0001 2.0 (1.7, 2. 5) <0.0001 1.4 (1.1, 1.7) 0.0010 1.4 (1.1, 1.8) 0.0006
Race and Ethnicity ·· <0.0001 ·· <0.0001 ·· 0.0004 ·· 0.022
    Hispanic vs Non-Hispanic White 1.0 (0.8, 1.2) 0.95 0.8 (0.6, 1.0) 0.030 1.8 (1.3, 2.4) <0.0001 1.7 (1.2, 2.3) 0.0008
    Non-Hispanic Asian vs Non-Hispanic White 0.4 (0.3, 0.6) <0.0001 0.5 (0.3, 0.7) <0.0001 1.0 (0.6, 1.6) 0.98 1.0 (0.6, 1.6) 0.96
    Non-Hispanic Black vs Non-Hispanic White 1.0 (0.7, 1.3) 0.79 0.9 (0.7, 1.2) 0.44 1.2 (0.9, 1.6) 0.42 1.3 (0.9, 1.8) 0.25
    Non-Hispanic Other vs Non-Hispanic White 0.8 (0.5, 1.3) 0.48 0.7 (0.4, 1.1) 0.12 1.3 (0. 8, 2.3) 0.48 1.2 (0.7, 2.1) 0.40
    Unknown vs Non-Hispanic White 0.2 (0.2, 0.4) <0.0001 0.2 (0.1, 0.4) <0.0001 1.9 (1.0, 3.8) 0.036 1.3 (0.6, 2.6) 0.43
Diabetes 2.8 (2.2, 3.4) <0.0001 ·· ·· 1.1 (0.9, 1.4) 0.31 ·· ··
BMI category (normal = reference group) ·· <0.0001 ·· <0.0001 ·· 0.48 ·· 0.33
    Underweight vs normal weight 0.5 (0.3, 0.9) 0.016 0.3 (0.2, 0.6) <0.0001 1.3 (0.8, 2.0) 0.24 1.3 (0.8, 2.0) 0.20
    Overweight vs normal weight 1.2 (1.0, 1.5) 0.17 1.0 (0.8, 1.3) 1.00 1.1 (0.8, 1.4) 0.71 1.1 (0.8, 1.4) 1.00
    Obesity vs normal weight 1.6 (1.2, 1.9) <0.0001 1.5 (1.2, 1.9) 0.0008 1.2 (0.9, 1.6) 0.21 1.2 (0.9, 1.7) 0.11
Smoking status (never = reference group) ·· <0.0001 ·· <0.0001 ·· <0.0001 ·· <0.0001
    Current smoker vs. never 1.6 (1.1, 2.4) 0.024 1.3 (0.8, 1.9) 0.47 1.4 (0.7, 2.9) 0.32 1.2 (0.6, 2.5) 0.58
    Former smoker vs. never 1.2 (0.9, 1.6) 0.21 1.1 (0.8, 1.4) 1.00 1.1 (0.8, 1.5) 0.43 1.1 (0.8, 1.4) 1.00
    Unknown/not asked vs. never 5.5 (4.3, 7.0) <0.0001 5.1 (3.9, 6.5) <0.0001 2.8 (2.1, 3.7) <0.0001 2.7 (2.0, 3.5) <0.0001
Median <200% vs ≥200% income 1.5 (1.3, 1.8) <0.0001 1.3 (1.1, 1.6) 0.0016 1.1 (0.9, 1.4) 0.38 0.8 (0.6, 1.1) 0.078
Binary logistic models for death
<65 ≥65
Univariable Multivariable Univariable Multivariable
OR (95% CI) p-value OR (95% CI) p-value OR (95% CI) p-value OR (95% CI) p-value
Sex (Male vs. Female) 3.1 (1.5, 6.3) 0.0008 2.8 (1.3, 5.9) 0.0034 1.2 (0.9, 1.6) 0.11 1.2 (0.87, 1.6) 0.23
Race and ethnicity ·· 0.63 ·· 0.72 ·· 0.0092 ·· 0.051
    Hispanic vs Non-Hispanic White 1.6 (0.7, 3.6) 0.36 1.5 (0.6, 3.5) 0.65 1.1 (0.8, 1.6) 0.60 1.1 (0.7, 1.7) 0.65
    Non-Hispanic Asian vs Non-Hispanic White 0.7 (0.1, 3.7) 0.58 0.4 (0.0, 4.1) 0.36 1.9 (1.2, 3.2) 0.0088 1.7 (1.0, 3.0) 0.042
    Non-Hispanic Black vs Non-Hispanic White 1.6 (0.6, 4.3) 0.53 1.6 (0.6, 4.2) 0.65 0.9 (0.6, 1.4) 0.61 0.9 (0.6, 1.4) 0.65
    Non-Hispanic Other vs Non-Hispanic White <0.001(-inf, inf) 1.00 <0.001(-inf, inf) 1.00 0.8 (0.4, 1.7) 1.00 0.9 (0.4, 1.8) 1.00
    Unknown vs Non-Hispanic White 1.8 (0.5, 6.9) 0.30 1.6 (0.4, 6.1) 0.44 2.5 (1.2, 5.2) 0.012 2.2 (1.0, 4.8) 0.037
Diabetes 3.0 (1.6, 5.6) 0.0001 ·· ·· 1.4 (1.0, 1.9) 0.011 ·· ··
BMI category (normal as reference group) ·· 0.32 ·· 0.22 ·· <0.0001 ·· 0.0004
    Underweight vs normal weight <0.001 (-inf, inf) 0.98 <0.001 (-inf, inf) 0.98 1.9 (1.2, 3.0) 0.0072 1.9 (1.1, 3.1) 0.0086
    Overweight vs normal weight 0.8 (0.3, 1.9) 0.48 0.6 (0.2, 1.5) 0.20 0.7 (0.5, 1.0) 0.024 0.7 (0.5, 1.0) 0.067
    Obesity vs normal weight 1.4 (0.6, 3.0) 0.34 1.2 (0.6, 2.7) 0.55 0.7 (0.5, 1.0) 0.066 0.8 (0.5, 1.1) 0.22
Smoking status (never as reference group) ·· 0.016 ·· 0.054 ·· 0.0002 ·· 0.0030
    Current smoker vs. never 1.6 (0.4, 6.5) 0.43 1.4 (0.3, 5.6) 0.63 2.1 (1.0, 4.8) 0.070 2.0 (0.9, 4.6) 0.14
    Former smoker vs. never 1.8 (0.8, 4.4) 0.13 1.7 (0.7, 4.3) 0.18 1.6 (1.1, 2.2) 0.0078 1.6 (1.1, 2.4) 0.0046
    Unknown/not asked vs. never 2.7 (1.3, 5.4) 0.0015 2.4 (1.2, 5.0) 0.0065 1.9 (1.4, 2.7) <0.0001 1.7 (1.2, 2.4) 0.0024
Median <200% vs ≥200% income 1.5 (0.8, 2.8) 0.24 1.2 (0.6, 2.3) 1.00 1.1 (0.8, 1.4) 0.62 1.0 (0.7, 1.5) 1.00
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Patterns for the joint exposure of BMI and diabetes on disease severity varied according to age group. Among those under the age of 65, and relative to patients with normal weight and no history of diabetes, the lowest odds of disease severity were observed among those with a BMI ˂18.5 and no prior diagnosis of diabetes (OR = 0·4, 95%CI: 0·2–0·7). By contrast, the highest odds of disease severity were observed among individuals with BMI ≥30 and a documented history of diabetes (OR = 3·5, 95%CI: 2·6–4·8; Fig 1A). Among patients 65 years of age or older, an elevate odds of increased disease severity was observed among those with a history of diabetes and a BMI > 30 (OR = 1.5, 95%CI: 1.0–2.1; Fig 1B).

Fig 1.

Fig 1

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Forest plot of adjusted risk factors for COVID-19 disease severity among patients (A) <65yo and (B) ≥65yo.

Age-related differences were also observed for the joint association of BMI and diabetes on mortality. Among patients younger than 65, those with diabetes and normal range BMI (OR = 2·6, 95%CI: 1·4–5·0) and those with diabetes and BMI ≥30 (OR = 2·9, 95%CI: 1.1–7·5) were at elevated odds for mortality (Fig 2A). Among patients over the age of 65, elevated mortality was observed among those with BMI <18·5, both among those without (OR = 2·0, 95%CI: 1·2–3·3) and with (OR = 3·1, 95%CI: 1·7–5·7) history of diabetes (Fig 2B). Increased odds of mortality were also observed for those with diabetes and normal BMI range (OR = 1·6, 95%CI: 1·2–2·1), whereas the odds of mortality were slightly lower for patients with overweight without diabetes (OR = 0·69, 95%CI: 0·48–1·00); albeit these latter findings were of borderline statistical significance.

Fig 2.

Fig 2

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Forest plot of adjusted risk factors for COVID-19 mortality among patients (A) <65yo and (B) ≥65yo.

Causal mediation

In causal mediation models among those younger than 65 years of age, 30% (95%CI:19%-50%) of the association between obesity and disease severity at a level requiring mechanical ventilation or death was mediated by diabetes (Table 3). The proportion mediated (PM) was slightly smaller for the other severity outcomes (PMICU = 29%, 95%CI 18%-49% and PMHospitalization = 19%, 95%CI 12%-36%).

Table 3. Proportion of the association between obesity and disease severity mediated by diabetes in participants age <65 years.

Severity score response Average proportion mediated (95% CI)
Not admitted into the hospital 0.24 (0.15, 0.42)
Admitted into the hospital 0.19 (0.12, 0.36)
Admitted into ICU 0.29 (0.18, 0.49)
Mechanical ventilation or death 0.30 (0.19, 0.50)
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Discussion

In this sample, diabetes accounted for 19–30% of the association between obesity and COVID-19 severity among individuals younger than 65yo. In both age groups, those with both obesity and diabetes had the highest odds of increased disease severity. Among patients older than 65yo, being underweight increased the risk of mortality regardless of diabetes history, whereas overweight seemed to potentially confer a slight survival benefit among patients without a history of diabetes. Our findings raise key clinical questions about age-specific relationships between weight status and COVID-19 outcomes, while documenting which patients may be at elevated risk for hospitalization and adverse outcomes [22].

By design, this study operationalized the mediator of the relationship between weight and COVID-19 outcomes as prior diagnosis of diabetes to distinguish the contribution of pre-existing diabetes from hyperglycemia occurring during hospitalization among COVID-19 patients without prior history of diabetes. In-depth considerations of glucometabolic parameters are often impractical in the context of critical care, and the concordance between historical glucose regulation documented in the medical chart and glycemic control at the time of admission is equivocal. Conceivably, a greater proportion mediated would be observed if the sample was limited to individuals with poorly controlled blood glucose, and prospective metabolic studies are needed to capture variations in glycemic regulation over the course of COVID-19 progression. Nevertheless, our findings are not trivial in indicating that a prior diagnosis of diabetes, even in absence of additional information, accounted for a meaningful proportion of the association between obesity and COVID-19 severity.

Similar to findings in the younger age group, the combination of obesity and diabetes increased the odds of greater illness severity among patients 65 and older. However, the magnitude of the effect was attenuated. Importantly, individuals with a BMI <18.5 were at increased risk of mortality regardless of diabetes history. This finding contrasts with widely publicized relationships between obesity and COVID-19 severity, while consistent with studies documenting age-specific relationships between obesity and COVID-19 outcomes [5, 6, 28]. For instance, a study conducted in Southern California found associations between BMI and mortality in COVID-19 patients, particularly among individuals under the age of 60 [8]. In another study conducted in New York City, obesity was associated with respiratory failure but not in-hospital mortality [28]. To our knowledge, our findings linking underweight status and increased mortality risks have not been widely reported in the literature. Underlying frailty or associated diseases are possible explanators of underweight-associated mortality.

The current results are not entirely consistent with previous studies have reported greater odds of poor outcomes among African Americans and Hispanics and those with lower SES [29]. Racial and ethnic minorities, and those with lower SES who seek regular care within the CSHS may not be representative of the larger population in Los Angeles. This explanation is in-line with the null association reported between race and ethnicity and COVID-19 related mortality from an analysis of data from Kaiser Permanente Southern California, an integrated health care organization [8]. Missing data on race and ethnicity might also mask inequalities [30]. Additionally, the limitations of zip-code based measures as proxy for individual-level income are well documented.

Limitations

First, it is important to acknowledge that our sample was limited to patients who regularly receive care at a large, urban hospital system. While the availability of objective anthropometric measurements, documented diabetes history and other EHR data increases the rigor of our results, our findings may not be representative of the larger population of individuals with COVID-19 who sought care at a tertiary medical center. Second, history of diabetes and height and weight data were extracted from EHR, however the recency of the data was not considered, thus potentially introducing discrepancy between current and historical data and overall lack of granular specificity of the Charlson comorbidity score used. Finally, the cut-point of 65 years used in the stratification was selected based on definitions used in similar studies [23] and health services research. Conceivably, different cut-offs may reveal different findings.

Conclusions

This study raises interesting clinical questions about age-specific relationships between weight status, metabolic risk factors and COVID-19 outcomes, while documenting which patients may be at elevated risk for hospitalization and adverse outcomes. Identifying heuristics that clinical staff can utilize to make decisions considering the persistent strain of the COVID-19 pandemic may improve patient outcomes and relieve staff burnout. In the absence of risk markers in the general population, these findings and others highlight the importance of self-management skills and regular medical care among patients with diabetes. COVID-19 has had a disproportionate impact on people with diabetes in challenging adherence and access to diabetes care, thereby potentially resulting in poorer diabetes control and related complications. More in-depth prospective studies are needed to document how glycemic regulation before and after infection influence prognosis.

Acknowledgments

The authors wish to thank the participants who were included in this analysis.

Data Availability

The data that support the findings of this study are available from Cedars-Sinai Medical Center, upon reasonable request. The data are not publicly available due to the contents including information that could compromise research participant privacy/consent. Please direct inquiries to: biodatacore@cshs.org.

Funding Statement

The manuscript was partially supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK; 1R01DK130851) and the Hope Warschaw Center for Integrated Research in Cancer and Lifestyle (Hope Warschaw CIRCL) awarded to SJS, and the by the National NIDDK Eris M. Field Chair in Diabetes Research (P30-DK063491) awarded to MOG. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIDDK and the Hope Warschaw foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Decision Letter 0

Fernando A Wilson

27 Jan 2022

PONE-D-21-25945

How useful are body mass index and history of diabetes in COVID-19 risk stratification?

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Reviewer #1: This manuscript addresses an important issue and presents novel and interesting results. The manuscript is clearly written, and the major limitations are acknowledge. Unfortunately, my version of the manuscript did not include any tables, despite the fact that 2 tables were referenced in the notes section. There are significant omissions of data, I suspect largely due to the missing tables.

Specific points:

- Please provide a summary of the demographic and clinical data of the sample. This is important to evaluate the generalizability of the results.

-Although measures race/ethnicity, income/socioeconomic status, and smoking history are mentioned in the methods, I see no mention of them anywhere else in the results. Please comment on the influence of these factors on disease severity and mortality in your sample.

Reviewer #2: This study evaluated patients treated at a single medical center for COVID-19 in a retrospective manner looking at how BMI, diabetes, and age influence COVID-19 related outcomes including hospital admission, ICU admission, mechanical ventilation, and death.

They found that up to 30% of obesity related morbidity/mortality in COVID-19 is due to diabetes. In addition, they found that patients with age >65 years who are underweight have a higher odds ratio for adverse outcomes in COVID-19 whereas those age >65 with BMI >30 may have a lower odds ratio for adverse events.

My opinion overall is that this study asks an important question (what is the interaction between obesity and DM in COVID19 outcomes), has sound methodology, draws results and conclusions supported by the presented data, and reasonably addresses limitations. However, the writing needs refining to be more clear, references need to be more appropriately used, and tables 1 and 2 need to be presented for review.

I favor accepting this manuscript with these minor changes.

Commentary:

Introduction:

Overall the introduction needs to be re-worked to discuss the current literature on the relationship between COVID-19 outcomes, obesity, age, and diabetes more clearly as in its current form it reads ambiguously.

Paragraph 1 – reference 1 does not seem to be relevant as it is a commentary without primary data and does not address the question of obesity as the sentence it is cited in does – I would consider changing this sentence so the reference is relevant or removing it altogether

Paragraph 1 – reference 12 does not discuss obesity, only discussing fasting blood glucose – it may be better used elsewhere

Paragraph 1 – sentence 2 – the authors mention hyperlipidemia but this disease is not mentioned elsewhere in the manuscript at all and does not make sense in the context of the paragraph. I wonder if this was meant to state increased BMI instead. If it was referring to hyperlipidemia specifically, it should be further expounded upon.

Paragraph 1 – reference 13 – the content of this reference (diabetes and lung function) is not explicitly discussed in the paragraph – may consider either adding content or removing this reference.

Paragraph 1 – reference 17 – this reference does not seem relevant as it is related to fasting glucose and pancreatic cancer, is a negative study, and does not mention COVID-19, and is not specifically brought up in the manuscript text

Paragraph 1 – reference 17 – the content of this reference (obesity and lung function) is not explicitly discussed in the paragraph – may consider either adding content or removing this reference.

Paragraph 1 – reference 19 – the content of this reference (pulmonary thrombosis in COVID-19) is not discussed - may consider either adding content or removing this reference.

Paragraph 1 – The final two sentences regarding the difference between scientific pursuits and clinical care are of unclear utility – I am not sure what the point of these are in context of the paper especially since these concepts are never referred to again in the manuscript.

Methods:

Overall these are largely well written and easy to follow.

Demographics – the authors state ‘median household income 200% below the federal poverty line’ – I believe what is meant is ‘median household income below 200% of the federal poverty line’

Body Mass Index – it is stated that last known height and weight were used – authors should clarify if these are prior to COVID diagnosis or after.

Body Mass Index – reference 10 doesn’t need to be cited as using baseline as a comparator group is standard

Analytic Plan – reference 25 does not specify why cut point of 65 is used, only that is frequently used.

Results:

Overall, results section is somewhat confusing to follow, going from age <65 cohort and causal mediation to age >65 cohort and mortality associations, then looking at the interactions between BMI and diabetes by age. It may be clearer to separate this section into patient characteristics first, then univariate associations, then multivariate associations (interactions between BMI, diabetes, and age), then finally causal mediation. This may help the important findings of the paper read more clearly.

Table 1 and table 2 were not available for my review and should be made available.

Discussion:

Overall, the discussion section is fairly clear and easy to understand, and is supported by the data presented.

Limitations:

The second paragraph of the limitations as they discuss racial/ethnic disparities is not really part of limitations and would fit better in the discussion section.

Conclusions:

Overall, the conclusion is supported by the data presented and makes reasonable inferences about need for diabetes care in the general population in the setting of COVID-19.

FIGURE 1 AND 2

None of the strata have an OR of 1 – which group is the reference group in this setting that the rest are being compared to?

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Reviewer #1: No

Reviewer #2: No

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Decision Letter 1

Fernando A Wilson

3 Mar 2022

How useful are body mass index and history of diabetes in COVID-19 risk stratification?

PONE-D-21-25945R1

Dear Dr. Salvy,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Fernando A. Wilson, PhD

Academic Editor

PLOS ONE

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