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Editor's Note
September 9, 2020

Regardless of Age, Obesity and Hypertension Increase Risks With COVID-19

Author Affiliations
  • 1NYC Health and Hospitals, New York
  • 2Deputy Editor, JAMA Internal Medicine
JAMA Intern Med. 2021;181(3):381. doi:10.1001/jamainternmed.2020.5415

Older age has consistently been associated with higher mortality in patients with coronavirus disease 2019 (COVID-19).1,2 Unfortunately, as shown by Cunningham et al3 in this issue of JAMA Internal Medicine, COVID-19 does not spare young people. Using a national all-payer hospital database, the investigators identified 3222 nonpregnant adults aged 18 to 34 years who were admitted to US hospitals for COVID-19. Morbidity was substantial: 21% required intensive care, and 2.7% died. Mortality was higher among those who had obesity, hypertension, and male sex, as has been noted in general adult populations.

Combined with what we know about the greater risk of older persons, what does this study tell us about COVID-19 and young adults? First, while young adults are much less likely than older persons to become seriously ill, if they reach the point of hospitalization, their risks are substantial. Second, obesity, hypertension, and male sex put patients of all ages at greater risk. As obesity and hypertension are preventable and treatable conditions, reducing the risk of serious COVID 19 illness should be added to the already long list of reasons to increase medical and public health efforts in young adults to promote healthful diets and increased exercise. Finally, the article by Cunningham et al3 establishes that COVID-19 is a life-threatening disease in people of all ages and that social distancing, facial coverings, and other approaches to prevent transmission are as important in young adults as in older persons.

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Article Information

Published Online: September 9, 2020. doi:10.1001/jamainternmed.2020.5415

Corresponding Author: Mitchell Katz, MD, NYC Health and Hospitals, 125 Worth St, Room 514, New York, NY 10013 (mitchell.katz@nychhc.org).

Conflict of Interest Disclosures: None reported.

Gasselli  G, Greco  M, Zanella  A,  et al.  Risk factors associated with mortality among patients with COVID-19 in intensive care units in Lombardy, Italy.   JAMA Intern Med. Published online July 15, 2020. doi:10.1001/jamainternmed.2020.3539Google Scholar
Guptas  S, Hayek  SS, Wang  W.  et al.  Factors associated with health in critically ill patients with coronavirus disease 2019 in the United States.   JAMA Intern Med. Published online July 15, 2020. doi:10.1001/jamainternmed.2020.3596Google Scholar
Cunningham  JW, Vaduganathan  M, Claggett  BL,  et al.  Clinical outcomes in young US adults hospitalized with COVID-19.   JAMA Intern Med. Published online September 9, 2020. doi:10.1001/jamainternmed.2020.5313Google Scholar
2 Comments for this article
Should age stratification be used to evaluate the severity of COVID-19?
Jianshe Yang, Ph.D | Department of Gastroenterology, Third Affiliated Hospital of the Chinese University of Hong Kong, Shenzhen 518172, China

COVID-19 pandemic has resulted in huge disaster to our humankind. As reported in a recent study in JAMA Internal Medicine,1 young adults, who have more than one conditions like morbid obesity, hypertension, and diabetes, had substantial rates of adverse outcomes when they were hospitalized with COVID-19. Although the limitations of this study include the misclassification by ICD-10 codes and variable reporting of race and ethnicity across hospitals, the high risk of severe outcomes is unquestionable. Seemingly these results are contradictory to the previous report2 that very few youngsters in patients with COVID-19 developed severity, possibly because that the status
of endothelium in youngsters is usually much better than elders and is more resistant to viral attacks3. In fact, the endothelium has the susceptibility to SARS-CoV-2,4 and the increased levels of circulating endothelial cells (CECs, derived from the normal endothelium damage) appear to be associated with severe forms of COVID-19, those who required admission to the intensive care unit (ICU) had significantly higher CECs than patients who did not require treatment in the ICU. In addition, the extent of endothelial injury was correlated with disease severity and inflammatory cytokines 5. This conclusion relies on the essentially healthy youngsters without morbid obesity, hypertension, or diabetes. We should not simply group  COVID-19 patients by age. Instead, physicians should consider the basic condition of patients with COVID-19 admitted to hospital.

1. Cunningham JW, Vaduganathan M, Claggett BL, et al. Clinical outcomes in young US adults hospitalized with COVID-19. JAMA Intern Med. 2020. doi:10.1001/jamainternmed.2020.5313
2. Ludvigsson JF. Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults. Acta Paediatr. 2020;109(6):1088-1095. doi: 10.1111/apa.15270
3. Hepponstall M, Chan A, Monagle P. Anticoagulation therapy in neonates, children and
adolescents. Blood Cells Mol Dis. 2017;67:41-47. doi: 10.1016/j.bcmd.2017.05.008
4. Varga Z, Flammer AJ, Steiger P, et al. Endothelial cell infection and endotheliitis in COVID-19. Lancet. 2020;395(10234):1417-1418. doi: 10.1016/S0140-6736(20)30937-5
5. Guervilly C, Burtey S, Sabatier F, et al. Circulating endothelial cells may serve as a marker of COVID-19 severity. J Infect Dis. 2020. doi:10.1093/infdis/jiaa528.
Causality Between Hypertension and COVID-19
Michael McAleer, PhD(Econometrics),Queen's | Asia University, Taiwan
It is disconcerting though not surprising that obesity and hypertension increase risks associated with COVID-19, regardless of age.

Hypertension as an existing condition may increase the risk of contracting COVID-19 and experiencing the more severe symptoms of the disease.

As social distancing, self isolation, quarantine, and lockdowns lead to increased stress, anxiety, and even more serious mental health issues, regardless of age, it would be useful to determine whether COVID-19 increases hypertension in a vicious and repeating cycle.