Indeed, obesity and COVID-19 are twin pandemics and are exacerbating each other. The COVID‐19 pandemic is occurring as obesity is sharply increasing in almost all countries around the globe, including Indonesia. In fact, in most countries, more than 20 percent of people are overweight or obese. Currently, we cannot mention a single country in the world that has been able to overcome an overweight-obesity epidemic.

Weight and height can be used to calculate a number called the body mass index (BMI). For most people, BMI is a good estimate of whether one is overweight or obese. A BMI of 25 to 29.9 is considered overweight, and a BMI of 30 or higher is categorized as obese. Weight epidemics have increased significantly over the last three decades both in the developed and developing worlds, including Indonesia.

This phenomenon inspired Barry Popkin, a prominent nutrition epidemiologist, to publish an important article called "The World is Fat", which appeared a few years ago in Scientific American Magazine and coined the word "globesity".

The Indonesian Health Ministry’s 2018 Basic Health Survey (Riskedas), the first update since the 2013 survey, sends a clear message that obesity is increasing in the archipelago. The survey shows that adult obesity doubled in 10 years, affecting about one fifth of the population over the age of 18.

The increasing prevalence of obesity, which makes people prone to chronic diseases, has become a triple burden for a country that is still battling various infectious diseases and emerging or reemerging diseases. If the government and communities do not immediately create comprehensive programs to strengthen people’s awareness of healthy lifestyles and their skills to live them, the country may suffer from greater health risks and costs now and in the future, which is also bad news for the struggling national health insurance program.

Several studies, including a recent systematic review led by Popkin, explain several ways that COVID-19 affects people with obesity more severely. First, obesity may weaken one’s immune response to SARS‐CoV‐2, the virus that causes COVID-19, because obesity has disturbing effects on key immune cell populations that are essential in the body’s response to the virus. An imbalance or disturbance in these cell subsets or functions is highly likely to hinder the immune response to the virus. Moreover, enhanced anti-inflammatory cells may weaken the body’s capability to combat the infection, as inflammatory responses play key roles in controlling the spread of viruses.

Second, obesity is closely related to various risk factors for COVID‐19, including hypertension, type 2 diabetes (T2D) and chronic kidney, liver and heart disease. An increasing body of evidence suggests that obesity is linked with physiological and metabolic impairment associated with COVID-19.

It is becoming common knowledge that obesity is a metabolic disease characterized by alterations in systemic metabolism, including insulin resistance, elevated serum glucose and chronic low‐grade inflammation.

Third, individuals with obesity frequently have more severe clinical symptoms and poorer prognoses. Studies have shown that obesity increases the hospitalization risk, severity and death risk for viral respiratory infections, including COVID‐19.

Adults with obesity are more likely to develop acute respiratory distress syndrome (ARDS), obstructive sleep apnea and other respiratory dysfunctions. They also often have an increased risk of hypoventilation‐associated pneumonia and pulmonary hypertension, which may lead to cardiac stress.

It is also noteworthy that obesity, indicated by greater body mass and larger waist circumference, may exacerbate the challenges of treatment and care for crucial and supportive therapies in the hospital, such as mask ventilation, intubation and prone positioning to assist in decreasing abdominal tension and enhancing diaphragm capacity. These circumstances may increase the chance of death.

While we are now preparing for COVID-19 vaccination, it is important to note that being a person with obesity has also been shown to impair the development of immunological memory. Numerous experts have warned that COVID-19 vaccines may be less effective in people living with obesity.

Finally, obesity and COVID‐19 have a reciprocal relationship. COVID-19 is potentially exacerbating obesity epidemics in many countries because it has caused significant changes in food supplies, food consumption and human behavior. Various links of food supply chains have been disrupted; the consumption of processed and fast food has increased among many people; and working from home may worsen sedentary lifestyles and impede physical exercise.

COVID-19 and obesity are worsening each other, and therefore, people living with obesity should be considered a vulnerable group that urgently needs comprehensive support.

In the Indonesian context, COVID-19 offers a lesson about the increasing threat of risk factors and comorbidities, including obesity, and has shown that we urgently need better policies, programs and human resources to tackle these issues.

--------

Senior lecturer at the Hasanuddin University Faculty of Public Health, senior fellow at the Partnership for Australia-Indonesia Research (PAIR)