Those excess pounds are something to worry about during a viral pandemic. Obesity increases the risk of dying from COVID-19. If you’re overweight, you are also at increased risk for hospitalization during this influenza pandemic.

We’re all scared. We’re all looking for good news. There is some, but first I’m here to tell the awful truth about excess pounds and influenza infections in hopes of saving your life or the life of someone you love.

The post image is courtesy of Image by mohamed Hassan from Pixabay

I Can’t Be Telling the Truth

“If the influenza pandemic were systematically killing fat people, the government would warn us.”

I don’t know why the CDC list of vulnerable populations advertised on every television station doesn’t include obesity as a risk factor. What the CDC tells us instead is that those of us who have high blood pressure, heart problems, diabetes, or compromised immune systems are at greater risk of getting sick, staying sick, and going into intensive care when we are infected with influenza. I guess we’re sort of, kind of, indirectly warned.

What Do They Know and When Did They Know It?

Image of H1N1 or Swine Flu virus which was the culprit in the pandemic of 2009.

The first inkling that obesity was a risk factor in an influenza pandemic came after the H1NI influenza pandemic of 2009.

H1N1, the Swine Flu

“Epidemiologic studies during the 2009 influenza pandemic highlighted for the first time that obesity was a high-risk factor for developing severe complications and dying from influenza virus infection (Schultz-Cherry, 2018).”

Early epidemiological studies on the Swine Flu showed a weak to moderate association between obesity and influenza severity (Cocoros et al., 2014, Sheridan et al., 2012). When obese people contracted the flu, they were sick longer, were more likely to be hospitalized and need critical care, and were more likely to succumb to the illness. Those were the early warnings that obesity increased the risk of dying during a viral pandemic.

When the first Avian Flu swept around the globe, the same phenomena were observed (Karlsson et al., 2016).

What About COVID-19?

Does obesity increase the risk of dying if you contract COVID-19? Are you more likely to need hospitalization and intensive care if you get sick with COVID-19? As we analyze the early data from the United Kingdom, the answers to each of these is “Yes”.

Boris Johnson is the current face of COVID-19 in the U.K. His primary risk factor is overweight. He was recently released from an I.C.U.

United Kingdom Intensive Care National Audit Report of COVID-19

On April 4, 2020, the ICNARC released its report on the COVID-19 pandemic in the United Kingdom. The report concluded that overweight and obese people are at risk of developing severe coronavirus related symptoms. To help us visualize the scope of the problem, think of the need for hospitalization for overweight and obese people in terms of hospital ICU beds. The figure below represents a typical intensive care unit with 10 beds. All of the beds in red are COVID-19 positive and obese or overweight people.

Imaginary Intensive Care Unit with 10 beds. In the average ICU in the United Kingdom, 7 of the 10 beds are occupied by overweight or obese COVID-19 patients.

Seventy percent of patients diagnosed with the corona virus and admitted to the intensive care units of hospitals in the United Kingdom are overweight or obese.

ICNARC 4/4/20

Only the Old Get Seriously Ill with COVID-19

On 4/17/20, Roni Rabin of the New York Times wrote an article entitled, “Especially for Younger Patients.” In the article, she described recent evidence showing that young people who are also obese are getting very ill, do require hospitalization, and can need intensive life support during the COVID-19 pandemic.

The Overweight Are Also At Higher Risk

The ICNARC report says something new and important about weight and the severity of influenza. The ICNARC report stratified COVID-19 positive Intensive Care patients by BMI (body mass index). In the figure below, the respiratory care needs of underweight (<18.5), normal weight (18.5-<25), overweight (25-<30), obese (30-<40), and morbidly obese (40+ ) patients are shown (from left to right). The orange line shows the percentage of patients by BMI in intensive care who needed basic respiratory support (oxygen), and the blue bars show patients in need of advanced respiratory support such as respirators.

Graph of the use of critical care in Intensive Care Units in the United Kingdom categorized by BMI.
ICNARC 4/4/20

Bottom Line: If we generalize from this data, half of U. S. citizens who are overweight and hospitalized for COVID-19 complications will probably need intensive respiratory care. Recent information from New York suggests that 80% of COVID-19 patients who’ve been placed on respirators die.

What Is the BMI Profile of Men and Women in the United States?

To see the risk for the average Joe or Jane, consider the average height and weight data for men and women in the United States. The average BMI for men and women in the U.S. is 29 or overweight. For the majority of us, the risk of serious complications from the current influenza pandemic is high.

Figure showing that the average man and woman in the United States has a BMI of 29, a number which makes half of us vulnerable to COVID-19.

What is your BMI? Calculate it here.

Why Does Being Overweight Make Us Vulnerable to Influenza?

Obesity and overweight suppress the immune system (Sheridan et al., 2012). Sheridan and colleagues were the first to study the anti-body and T-cell responses of obese individuals. They studied the immune response of lean and obese people vaccinated with a trivalent vaccine in 2009. Although overweight people showed an initial strong response to the vaccine, their ability to mount a defense against the viral challenge declined more than four times over a year.

Chart showing reduced immune response of obese versus healthy weight people to an influenza vaccine.

How Obesity Weakens the Immune System

Adults with obesity have a weakened immune response characterized by:

  • Blunted lymphocyte response to myogenic or antigenic stimulation
  • Reduced numbers of lymphocytes (CD3+, CD4+, CD8+, B cells)
  • Lower naive lymphocyte output
  • Skewed T-cell phenotype
  • Impaired macrophage and natural killer cell function

Obesity Causes Premature Aging of the Immune System

In both mice and humans, obesity induces premature thymic involution and decreases thymic output, a phenomenon similar to that seen in aging (Dao et al., 2020). For definitions, see Ballantyne (2013) or follow link.

I Didn’t Know I Had a Thymus Gland

I’d heard of the thymus gland, but I didn’t have a clue about its importance. The thymus gland is kind of a big deal. It’s a primary player in the immune system. T-cells, critical to our body’s ability to fight foreign invaders such as the virus, develop in the thymus.

The thymus gland. A Getty image.

What Does Having a Weakened Immune Response Mean?

The weakening of immune cell function with age and obesity translates into:

  • Higher risk of infections
  • Reduced effectiveness in responding to new pathogens
  • Decreased response to vaccines
  • Increased risk for chronic inflammatory conditions including autoimmune disease
  • Low-grade chronic inflammation with higher circulating concentrations of C-reactive protein and interleukin 6.

It’s Not Obesity, It’s Diabetes and Other Co-morbid Conditions

You might be tempted to reject the idea that those extra pounds you’re carrying about are weakening your body’s ability to defend you against a viral challenge. You might argue that the obese people who can’t fight off the flu have other medical problems such as diabetes. You don’t have diabetes, so you’re okay.

You’d be wrong. Body mass alone can predict a lessened response to a viral challenge. Moser and colleagues (2019) looked at the effect of body mass on influenza sequelae for four influenza seasons.

[…] adults who are underweight or morbidly obese, even if they do not have chronic conditions that increase the risk of influenza -related complications, may be at increased risk of developing severe disease due to seasonal influenza infection […].

Moser et al., 2019

Does Sneezing Make You Crazy?

Edison's kinetoscopic image of the first film taken of a sneeze. The image was part of a patent application.

Edison’s kinetoscopic record of the first sneeze ever filmed. Scan the film down the left column, the next column, and so on. The famous sneezer is Fred Ott, a mechanic in Edison’s laboratory. Image from the Library of Congress

Do you start to itch when the person behind you in a crowded venue coughs or sneezes? Must you suppress an urge to leave or hand the offender a tissue? What you’re worrying about is viral shedding. Is the infectious stuff inside the other guy going to make its way to you?

Viral Shedding and Influenza

Viral shedding is real, and it’s something to worry about. Maier and colleagues (2018) did a ground breaking study. These researchers examined the RT-PCR response of everyone in a household when the symptoms of influenza were first detected. The nasal cavities of family members were swabbed for approximately two weeks to see if the virus was replicating and being shed. The virus was actively shed for nearly two weeks. (Figure below, pink = obese shedding; blue = nonobese shedding)

Image showing the amount of viral shedding for the first two weeks after a family member got the flu. Image shows that obese family members shed the virus for longer and remain contagious for longer.

Why Do Obese Family Members and Children Shed Longer

The Maier et al. study revealed that children and obese family members were capable of shedding the virus much longer than family members of normal weight. Why? Perhaps obese people don’t fight off a viral infection as quickly due to compromised immune systems. Children also stay sick with the flu longer. Anyone with a compromised immune system including the elderly and those with autoimmune disease may shed infectious materials for longer.

Must You Be Symptomatic to Shed a Virus?

No. For all recently studied influenza strains, individuals without symptoms or with mild symptoms shed the virus. You will not know if you’re shedding a virus until you’ve already infected other people.

If I Cough Into My Elbow or Into a Tissue, I Won’t Infect Anyone!

Take a look at the training video from the Centers for Disease Control. It tells children why it’s important to cover coughs and sneezes.

From the Centers for Disease Control

I wish the well intended advice from the CDC were sufficient, but it isn’t. Yan and colleagues (2018) studied the viral shedding of college students when they coughed, sneezed, or simply talked. They concluded, there is […] “overwhelming evidence that humans generate infectious aerosols.”

If We Talk, We Shed

Coughing or sneezing isn’t required for the virus to be shed into the air and affect another person. In nearly 40% of Yan et al. samples, infectious particles were released into the air by simply repeating the alphabet.

Read this again slowly. Let it sink in. If we talk to someone who is across from us in a checkout line, we’re shedding and so are they.

My Overweight Child Won’t Get COVID-19

Children seem to be faring better than adults during this pandemic, but children are contracting COVID-19. Some of them don’t survive. We don’t know which children are succumbing to COVID-19. Do these children have serious weight issues?

Err on the Side of Caution

As parents, be on the safe side and be extra vigilant if your child has weight issues. Model and teach safe sanitation practices. http://at-war-with-covid-19:-arming-your-home

If your child isn’t overweight, remember that your child could be a carrier of COVID-19 and not show symptoms. Being asymptomatic doesn’t mean you or your child aren’t shedding the virus and infecting someone else.

Think Before You Return Your Child to School or Events

If your child contracts COVID-19 or any other virus, use caution when returning him or her to social situations such as school or sports. An overweight child poses a double risk of shedding and could infect other children or teachers.

Stigmatizing High Risk Viral Shedders

One of the tragic consequences of COVID-19 is stigmatization of individuals of East Asian descent. Misguided people have verbally and physically assaulted those thought to be Chinese and hence responsible for the epidemic.

Please, please, don’t misapply the information in this post. Obese and overweight people didn’t cause the epidemic. We all did. Stigmatization is a major barrier to the recovery of the overweight and obese person. We need to bring each other up, not tear each other down.

Life in a Pandemic War Zone

Picture of a United States flag behind a a security fence. The purpose of the picture is to show that the virus is holding us prisoners.
Image by Barbara Rosner from Pixabay

Just reading this research can be depressing. Watching the research play out in real time on television throws me into a near-catatonic state. We’re at war with an invisible enemy– an enemy we can’t see and don’t understand.

I’ve made some lifestyle changes, and I’d like to share these with you. I hope these up to date sanitation practices will protect me and those I love.

I also came across some marvelous technology which can help us defeat pandemic infections in our own homes. We should all know about these advances. Follow the link. http://at-war-with-covid-19:-arming-your-home

Other Reading

We discuss obesity and stigma in our book, Confessions of a Carbohydrate Addict. It’s available from Amazon.

We’ve written about other aspects of obesity, illness, and weight loss.


I.C.N.A.R.C. (4/4/2020). ICNARC COVID-19 Study Case Mix Programme Database.

Ballantyne, S. (2013). The Paleo Approach: Reverse Autoimmune Disease and Heal Your Body. Las Vegas: Victory Belt Publishing, Inc.

Cocoros, N. M., Lash, T. L., DeMaria, A., Jr., & Klompas, M. (2014). Obesity as a risk factor for severe influenza-like illness. Influenza and other respiratory viruses, 8(1), 25-32. doi:10.1111/irv.12156

Dao, M. C., Saltzman, E., Page, M., Reece, J., Mojtahed, T., Wu, D., & Meydani, S. N. (2020). Lack of Differences in Inflammation and T Cell-Mediated Function between Young and Older Women with Obesity. Nutrients, 12(1). doi:10.3390/nu12010237

Honce, R., Karlsson, E. A., Wohlgemuth, N., Estrada, L. D., Meliopoulos, V. A., Yao, J., & Schultz-Cherry, S. (2020). Obesity-Related Microenvironment Promotes Emergence of Virulent Influenza Virus Strains. mBio, 11(2), e03341-03319. doi:10.1128/mBio.03341-19

Karlsson, E. A., Hertz, T., Johnson, C., Mehle, A., Krammer, F., & Schultz-Cherry, S. (2016). Obesity Outweighs Protection Conferred by Adjuvanted Influenza Vaccination. mBio, 7(4). doi:10.1128/mBio.01144-16

Maier, H. E., Lopez, R., Sanchez, N., Ng, S., Gresh, L., Ojeda, S., . . . Gordon, A. (2018). Obesity Increases the Duration of Influenza A Virus Shedding in Adults. The Journal of Infectious Diseases, 218(9), 1378-1382. doi:10.1093/infdis/jiy370

Moser, J.-A. S., Galindo-Fraga, A., Ortiz-Hernández, A. A., Gu, W., Hunsberger, S., Galán-Herrera, J.-F., . . . La Red, I. L. I. S. G. (2019). Underweight, overweight, and obesity as independent risk factors for hospitalization in adults and children from influenza and other respiratory viruses. Influenza and other respiratory viruses, 13(1), 3-9. doi:10.1111/irv.12618

Murray, T. (2015). Repeated flu shots may blunt effectiveness. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 187(6), E180-E180. doi:10.1503/cmaj.109-5000

Schultz-Cherry, S. (2018). Beyond Disease Severity: The Impact of Obesity on Influenza A Virus Shedding. The Journal of Infectious Diseases, 218(9), 1354-1355. doi:10.1093/infdis/jiy371

Sheridan, P. A., Paich, H. A., Handy, J., Karlsson, E. A., Hudgens, M. G., Sammon, A. B., . . . Beck, M. A. (2012). Obesity is associated with impaired immune response to influenza vaccination in humans. Int J Obes (Lond), 36(8), 1072-1077. doi:10.1038/ijo.2011.208

Yan, J., Grantham, M., Pantelic, J., Bueno de Mesquita, P. J., Albert, B., Liu, F., Consortium, E. (2018). Infectious virus in exhaled breath of symptomatic seasonal influenza cases from a college community. Proc Natl Acad Sci U S A, 115(5), 1081-1086. doi:10.1073/pnas.1716561115

Linda J. Gummow

Linda J. Gummow

L. J. Gummow, Ph.D. and Robert E. Conger, Ph.D. are Clinical Psychologists. L. J. lost 25% of her body weight by following by reducing carbohydrates. In the process, she learned that much of what we're taught about weight loss is wrong. She and her co-author researched weight loss diets and the results show that sugar consumption is our public health enemy number one. R. E.

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