Perspective Obesity

COVID-19 AND OBESITY

Considerations for Obesity, Vitamin D, and Physical

Activity Amid the COVID-19 Pandemic
1,
Stephen J. Carter Marissa N. Baranauskas1, and Alyce D. Fly2

As the biomedical community races to disentangle the unknowns associated with severe acute respiratory
syndrome coronavirus 2, the virus responsible for causing coronavirus disease, the link between diminished
immune function and individuals with obesity raises important questions about the possibility for greater
viral pathogenicity in this population. Increased adiposity may undermine the pulmonary microenvironment
wherein viral pathogenesis and immune cell trafficking could contribute to a maladaptive cycle of local in-
flammation and secondary injury. A further challenge to those with obesity during the current pandemic may
involve vitamin D deficiency or insufficiency. In the interest of personal and public health, we caution deci-
sion- and policy makers alike not to pin all hope on a proverbial “silver bullet.” Until further breakthroughs
emerge, we should remember that modifiable lifestyle factors such as diet and physical activity should not
be marginalized. Decades of empirical evidence support both as key factors promoting health and wellness.
Obesity (2020) 28, 1176-1177. doi:10.1002/oby.22838

Continuing escalation of the novel coronavirus disease (COVID-19) sedentariness is the propensity for systemic deconditioning, a dilemma
pandemic has fueled an unprecedented response by governments to that can readily undermine overall health and wellness.
slow the incidence of infection and mortality. As of April 8, 2020,
real-time estimates from the Johns Hopkins University dashboard re- As the biomedical community races to disentangle the unknowns asso-
ported approximately 1.5 million COVID-19 cases worldwide, with ciated with COVID-19, the link between diminished immune func-
the United States accounting for 28% (1). As expected, various sectors tion and individuals with obesity raises important questions about the
have embarked on large-scale efforts to develop targeted therapeutics, possibility for greater viral pathogenicity in this population (2). Given
including monoclonal antibody therapy and vaccination; however, a the prevalence of obesity among the US population, a meaningful pro-
complex road lies ahead before success can be reached at the population portion of individuals may be at an elevated risk for symptom com-
level. Amid the growing concern, many governments have taken action plications following a positive COVID-19 diagnosis. Following the
by implementing travel restrictions, school closures, and social distanc- 2009 influenza A virus H1N1 pandemic, retrospective analyses spec-
ing to mitigate the strain on public health care systems. Similar tactics ified obesity as a risk factor for symptom severity and mortality (3).
have been effective at containing previous viral outbreaks, although a Increased adiposity may undermine the pulmonary microenvironment
natural consequence of these changes is the disruption of daily routines. (e.g., alveoli), wherein viral pathogenesis and immune cell traffick-
Nevertheless, there is urgent need to employ a multipronged approach ing could contribute to a maladaptive cycle of local inflammation and
to manage the crisis in both the short and long term. secondary injury. The spike glycoprotein residing on the membrane of
the COVID-19 virus will likely be of central importance, as it is the
Though COVID-19 is notoriously contagious, it also appears to be pref- key feature for host entry and is responsible for triggering the immune
erentially virulent among older (> 60 years) adults with existing comor- response (4). As work endeavors to resolve the challenges of COVID-
bidities, including obesity, hypertension, and diabetes. This would be 19 therapies, understanding how individuals with obesity may respond
expected, as overt and/or occult disease is known to increase vulnerabil- differently to such treatments will be critical.
ity to infections. Still, many infected individuals do not succumb to the
illness and, instead, fight the imposing effects of the virus. Depending Though somewhat speculative, a challenge to those with obesity during the
of the severity of symptoms, some patients present with acute respi- COVID-19 pandemic may involve vitamin D deficiency or insufficiency
ratory and/or cardiac distress necessitating mechanical ventilation and (5). Long recognized as the “sunshine vitamin,” the biologically active
prolonged hospital stays. However, a further matter of priority involves form of vitamin D (1,25-dihydroxyvitamin D/calcitriol) has been impli-
the preservation of health among those not diagnosed with COVID- cated in various inflammatory, infectious, and pulmonary diseases. Indeed,
19. Whereas social distancing and “sheltering in place” readily limit experimental evidence has indicated calcitriol exerts protective effects
person-to-person transmission, an undesired consequence of prolonged from lipopolysaccharide-induced lung injury by modulating the expression

1
Department of Kinesiology,  School of Public Health,  Indiana University, Bloomington, Indiana, USA. Correspondence: Stephen J. Carter ([email protected])
2
Department of Applied Health Sciences, School of Public Health, Indiana University, Bloomington, Indiana, USA.

© 2020 The Obesity Society. Received: 9 April 2020; Accepted: 14 April 2020; Published online 21 May 2020. doi:10.1002/oby.22838

1176     Obesity | VOLUME 28 | NUMBER 7 | JULY 2020 www.obesityjournal.org

Perspective Obesity
COVID-19 AND OBESITY

of angiotensin-converting enzymes I and II (6). Considering the growing health, we caution decision- and policy makers alike not to pin all hope
dispute over the proposed link between mortality and morbidity among on a proverbial “silver bullet.” Until further breakthroughs emerge, we
COVID-19 patients and use of angiotensin-converting enzyme inhibitors should remember that modifiable lifestyle factors such as diet and phys-
and angiotensin receptor blockers (7), it seems prudent to also consider ical activity should not be marginalized. Decades of empirical evidence
how interindividual variance in vitamin D status could be involved in pul- have supported both as key factors promoting health and wellness. In
monary inflammation and viral pathogenicity. Interestingly, emerging data times of crisis, whether it be real or perceived, there is something to be
posit vitamin D could be an adjunct to manage the proinflammatory milieu said about the benefits of empowering people to actively preserve their
or “cytokine storm” observed in COVID-19 patients (8). This, in turn, pres- own health.O
ents an attractive option, as the clinical implications of symptom severity Funding agencies: This publication was made possible, in part, with support from
and management appear to be exacerbated in the setting of hypertension the Indiana Clinical and Translational Sciences Institute funded by grant number
and diabetes, both of which are typically connected to obesity. UL1TR002529 from the National Institutes of Health, National Center for Advancing
Translational Sciences, Clinical and Translational Sciences Award.
Alternatively, physical activity, operationalized as energy expenditure Disclosure: The authors declared no conflicts of interest.
attributed to skeletal muscle contractions, is a pragmatic approach to aug-
ment vitamin D status, particularly when performed outdoors. Habitual References
outdoor physical activity is known to promote vitamin D synthesis through 1. Johns Hopkins University. COVID-19 Dashboard by the Center for Systems Science
the interaction between ultraviolet radiation and 7-dehydrocholesterol in and Engineering. https://gisan​ddata.maps.arcgis.com/apps/opsda​shboa​rd/index.html#/
bda75​94740​fd402​99423​467b4​8e9ecf6. Accessed April 8, 2020.
the skin. Directives to limit social contact notwithstanding, even indoor 2. Andersen CJ, Murphy KE, Fernandez ML. Impact of obesity and metabolic syndrome
physical activity may effectively improve vitamin D status through bio- on immunity. Adv Nutr 2016;7:66-75.
3. Sun Y, Wang Q, Yang G, Lin C, Zhang Y, Yang P. Weight and prognosis for influ-
logical mechanisms beyond 7-dehydrocholesterol. Prospective analyses enza A(H1N1)pdm09 infection during the pandemic period between 2009 and 2011:
of community-dwelling older adults over a 2.6-year period showed a a systematic review of observational studies with meta-analysis. Infect Dis (Lond)
positive association between the change in serum vitamin D (25(OH) 2016;48:813-822.
4. Dhama K, Sharun K, Tiwari R, et al. COVID-19, an emerging coronavirus infection:
D) and physical activity assessed by accelerometry independent of sun advances and prospects in designing and developing vaccines, immunotherapeu-
exposure (9). Scott et al. (9) indicated the observed relationship may have tics, and therapeutics [published online March 18, 2020]. Hum Vaccin Immunother.
been attributed to favorable changes in body composition via physical doi:10.1080/21645​515.2020.1735227
5. Pereira-Santos M, Costa PR, Assis AM, Santos CA, Santos DB. Obesity and vitamin D
activity (i.e., ↓adiposity; ↑skeletal muscle mass). It is also worth not- deficiency: a systematic review and meta-analysis. Obes Rev 2015;16:341-349.
ing that daily or weekly supplementation with vitamin D (D2 or D3) has 6. Xu J, Yang J, Chen J, Luo Q, Zhang Q, Zhang H. Vitamin D alleviates lipopolysaccha-
ride induced acute lung injury via regulation of the renin angiotensin system. Mol Med
been shown to offer protection from acute respiratory infections, partic- Rep 2017;16:7432-7438.
ularly among individuals exhibiting vitamin D deficiency (< 20 ng/mL) 7. Patel AB, Verma A. COVID-19 and angiotensin-converting enzyme inhibitors and an-
(10). However, among US adults, shifting attention to focus on a single giotensin receptor blockers: what is the evidence? [published online March 24, 2020].
JAMA. doi:10.1001/jama.2020.4812
micronutrient such as vitamin D should not be at the expense of other 8. Grant WB, Lahore H, McDonnell SL, et al. Evidence that vitamin D supplementation
commonly underconsumed nutrients, including calcium, potassium, and could reduce risk of influenza and COVID-19 infections and deaths. Nutrients 2020;12.
dietary fiber. A diverse diet will help ensure a broad nutrient profile to doi:10.3390/nu120​40988.
9. Scott D, Blizzard L, Fell J, Ding C, Winzenberg T, Jones G. A prospective study of
aptly alleviate vulnerability to acute and chronic disease. the associations between 25-hydroxy-vitamin D, sarcopenia progression and physical
activity in older adults. Clin Endocrinol (Oxf) 2010;73:581-587.
10. Martineau AR, Jolliffe DA, Hooper RL, et al. Vitamin D supplementation to prevent
Assuredly, our collective understanding will evolve in response to the acute respiratory tract infections: systematic review and meta-analysis of individual par-
COVID-19 pandemic. However, in the interest of personal and public ticipant data. BMJ 2017;356:i6583. doi:10.1136/bmj.i6583

www.obesityjournal.org  Obesity | VOLUME 28 | NUMBER 7 | JULY 2020     

1177