by | May 17, 2020 | COVID-19 Resources

Following publication of the society position statement https://www.karger.com/Article/FullText/508082 on the Global COVID-19 pandemic and obesity in Obesity Facts, the European Journal of Obesity, EASO was pleased to host a webinar with members of the Executive Committee, Obesity Management Task Force (OMTF) and Centres for Obesity Management (COMs) on Friday 8 May 2020 focused on obesity and the novel coronavirus.


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Okay, good afternoon colleagues, good afternoon to our friends from the IASO member associations, collaborating centres for obesity management and all colleagues from around the world. Thank you for joining this webinar, the IASO webinar on overweight and obesity as risk factors for COVID-19. This webinar is scheduled to last for approximately 90 minutes and we will start with some webinar housekeeping.

So if you would like to ask a question to any of the panellists, please only use the question and answer Q&A function. This is located at the bottom of the screen of your Zoom screen. So you just type your question and then press send.

A team from IASO will be monitoring the questions when you submit them. We will pose these questions directly to the panellists during the Q&A sessions. If we are unable to answer your question, we apologise, we will try to do so afterwards.

Be aware that sometimes we don’t have answers to all the questions in this fast-moving scenario. So the webinar will also be recorded and will be made available via IASO.org sometime after the session. So just for those who don’t know, IASO is the European Association for the Study of Obesity.

It was established in 1986 and it is a federation of professional member associations, currently from 34 countries, soon to be from 36 countries, and official relations with WHO regional office for Europe. We represent scientists, health practitioners, physicians, public health experts and patients, essentially everybody with a relationship to the obesity field. We promote action through collaboration in research, education and policy.

The agenda will take us through looking at obesity and COVID-19, association or causation, followed by Q&A. And then we will look at some clinical experiences and data from three different countries in our European region, France, Italy and Israel, followed by additional Q&A with some final remarks at the end. So now it gives me great pleasure to hand the webinar floor, the virtual floor, to Dr Nathalie Farpour-Lombert.

She is the Chief Medical Officer and Deputy Director of Child and Adolescent Health Service, CGTG, in Switzerland. She is also the President of the European Association for the Study of Obesity and the Director of the Contrepoix Service in Geneva. So Dr Farpour-Lombert, I hand the floor to you to formally open the webinar on behalf of IASHO.

Hello to everyone. It’s a great pleasure to open this webinar on COVID-19 and obesity. We all have been involved or affected by the COVID-19 pandemic and I would like to share a short reflection during the first weeks of the pandemic.

The COVID-19 was declared a pandemic by WHO on the 12th March 2020. It is likely to have a significant impact on the population, but in particular on people living with obesity. They have an elevated risk of hospitalization, serious illness, mortality, likely due to the chronic low brain inflammation and alternate immune response to infection, as well as related cardiometabolic comorbidities.

Emerging data now demonstrate that people with obesity may also experience more severe COVID-19 symptoms and may be more likely to need complex, intensive care treatment. Next slide, please. So we know that healthcare professionals, national health systems, and policy makers need access to evidence-based information and guidance to meet the healthcare needs of patients with obesity who have been affected by COVID-19.

They can’t see you. Next slide, please. Our global ability to adapt to the demands of the pandemic will be determined by our willingness to develop resilient systems that are particularly protective of high-risk individuals and vulnerable population.

For example, in France, obesity has been recognized as a major risk factor for severe forms of COVID-19, and this is partly important to protect people with obesity. The pandemics can influence thinking and drive maps of maladaptive behaviors among individuals through cognitive distortion. We know that quarantine and isolation may increase psychosocial stress in many ways, influenced by duration, the provision of information, especially by the media, the fear of infection, social and familial isolation, the availability of supplies, financial hardship, and stigmatization.

So there are many challenges to address. Next slide, please. So to respond to urgent COVID-19 healthcare needs, much health services delivery has been restructured, and elective nonessential medical and surgical procedures have been postponed.

For example, in Geneva, we have extended the number of beds, surfaces to be able to care for people with COVID-19, and the majority of resources have been put to address this issue, and all other normal activities have been stopped. For people with obesity, bariatric medical and surgical procedures have been among those canceled, and regular appointments of other non-acute patients have been scaled down, leaving many people with chronic disease without the appropriate care they need. We hope that the COVID-19 pandemic will pass, but we don’t know how it will be during the next months.

But the challenge to nurture our health in a meaningful and feasible way, and to avoid potential collateral effort, will remain probably for many months. We recognize that people with obesity face many challenges in their communities, including pervasive weight bias and stigma. To date, we need more research, more data on the association between obesity and COVID-19, especially severe forms of obesity.

We need more research in children to know if they should be considered as at-risk for severe forms of COVID-19. To date, we have very little evidence, but in Geneva, we have one child with obesity which needed intensive care. He’s doing well now.

So we are at the moment collecting data around the world to understand better the development of COVID in children with obesity, and we need also more research in adults to understand the relationships between obesity and COVID-19. The European Association for the Study of Obesity will continue to advocate for the importance of research and surveillance during and after the COVID-19 pandemic. Finally, we should not forget the population with normal weight initially, which has been affected by the confinement, isolation, and major changes, lifestyle changes.

And so France yesterday announced a mean weight gain of the population on 2.5 kilos during the confinement. So we may expect that more children, more adults will have developed or will develop obesity during the next weeks or months, and so we will have also more patients to take care of. So it’s really a great pleasure to introduce this webinar, and I would like to tell you that you can find a lot of resources on obesity and resources for patients, but also for healthcare professionals, for the general population on our website, and you will also find the information about the webinar on COVID-19 and obesity.

So now it’s a great pleasure to introduce Professor Hema Frubeck. She’s the past president of IESO, and I’m very proud. It’s an honor to follow your path, Hema.

She’s now the president of the Scientific Advisory Board of IESO, and she will present obesity and COVID-19, association or causation, coexistence of two pandemics. So the floor is yours. So hello everybody.

Can you hear me well? Yes. Yes. Okay, just checking.

It is a great pleasure to be able to interact with colleagues and with our huge community via this communication channel, and I really would like to send you all my very best wishes. I would also like to transmit my sympathy and also condolences to all those that have been affected either directly or indirectly by COVID-19, and as regards the contents that will be covered in my talk, I will start reviewing some epidemiological data, focusing particularly on the relation with obesity and also present some selective information from the beginning, from the very beginning until today in different countries. I will continue then mentioning the main clinical pathophysiological characteristics to focus on some of the potential mechanisms, underlying mechanisms that have been put forward, and to finish with some future perspectives and also some conclusions.

This is probably one of the most visited websites during the last months. As you know, it is the Johns Hopkins Coronary Viral Research Center that tracks in real time the evolution of the pandemic. Data from this morning just shows that over 3,800,000 cases are confirmed worldwide.

Almost a third of them belong to the US, but the next countries that are in the top ranking are European countries with Spain, Italy, United Kingdom, Russia, France, and Germany, for instance. It has to be said that this pandemic and this total confirmed cases have been identified in 187 countries, and unfortunately, the number of deaths is already close to 270,000, again led by the US, but followed also by European countries, in this case, UK, Italy, and Spain. This world map, however, for those of us working in the obesity field, really takes place on a well-known and simultaneous pandemic, which is the obesity pandemic.

As you know, the prevalence of obesity has tripled in the past decades, and now we know that the prevalences have increased from the more blue and greenish colors, which are a prevalence of obesity below 20%, to more reddish and orange colors, which, yes, indicate that the prevalence is above 30%, and in some cases, even 40% or 50%. As you know, these are also very scary data, and WHO in 2016 just identified that over 650 million adults over the age of 18 were people living with obesity. Worldwide, 39% of the people had overweight, and 33% were people living with obesity, and at least 2.8 million people were dying each year as a result of overweight or obesity.

So, it may seem that although obesity is a chronic and non-communicable disease, it can be sometimes neglected or even pass unnoticed, but the data are equally scary. So, the question now arises, as the COVID-19 pandemic is just coexisting with our obesity pandemic, to which we can add just the diabetes pandemic or the sedentarism pandemic, or if they are really linked and have an influence on each other. So, if we go to the data, the very first clinical data from the Chinese cohorts derived from the hospitals in Wuhan, but also in other Chinese hospitals, you can see that initially what strikes everyone is the age of the population.

It’s middle-aged patients. There is a difference for those that had to be admitted to intensive care unit or not. Those that really had to be admitted to ICU had an older age.

There was a preponderance of mates in this case, and also what strikes very clearly is the relation with comorbidities. For instance, for those admitted for intensive care unit, 72% exhibited comorbidities, which were recorded as hypertension, cardiovascular disease, diabetes, and so on. And this happens in other cohorts and also in the very early cohorts that I haven’t shown the exact data, but they are consistent.

And one of the things is the lack of BMI data. This is something that we always have to deal with. Probably it relates to not paying specific attention to obesity, but for those of us working in the obesity field, the constellation of comorbidities that we see in these patients as suffering COVID-19 is very closely related with what we see in our obese patients.

Data from Italy just showed that from 3,200 deaths, 34% of them had type 2 diabetes, 30% cardiovascular disease, and almost half of them presented three comorbidities. And interestingly, here obesity was reported among those young adults that just had a very fatal outcome. As regards information derived from the Intensive Care National Audit and Research Center in the UK, they have analyzed almost 7,000 ICU admissions, and in those critically ill patients, BMI really mirrored the general population.

So if we have a look at them, you see patients that were critically with confirmed COVID-19 are those that are in the blue bar graphs. If we compare those with the age-related and sex-matched general population, we see that in the extremes of the BMI ranges, we have fewer cases, but in the middle, like in the Gaussian distribution, we have most of the cases. But very interestingly, what they did was also to compare patients critically ill with viral pneumonia, but non-COVID-19 related, so from the past two years, and almost 6,000 individuals there.

And it’s very interesting to see that in the lower BMI ranges, it’s the non-COVID percentages that are higher, but as soon as we reach either the overweight or the obese BMI range, it’s really the COVID-19 patients that show a higher percentage. What happened in other parts of the world? So early clinical observations from Seattle, in a small cohort of 24 patients admitted to ICU, the mean BMI there was 33. Half of them almost just had type 2 diabetes, 21% of them obstructive sleep apnea, and half of them died over the short term.

In a larger cohort, in this case of patients with long-term care facilities, obesity was present in 22%, as was type 2 diabetes in 23% of them. And the Centers of Disease Control and Prevention, the CDCs, has analyzed the underlying conditions among COVID-19 hospitalizations in 14 states all over the month of March. And it’s very interesting to see how, in this case, when we look at the population overall, obesity really features very strongly.

So almost half of the patients had obesity, but they also had hypertension, chronic lung disease, and diabetes to a lesser extent. But especially when coming to the younger age group, it was really obesity with 59% the underlying condition that was really the driving force. As patients were in the elder age groups, obesity was still present, but it decreased a little bit.

And in the very old ones, it was more hypertension that features more markedly. So taken together, this led to obesity being included as one of the risk factors for severe COVID-19 development. And we also have to take into account then patients living with obesity had also an increased mortality from the disease.

If we plot the severity of the illness over time, we can identify three clearly distinguished phases. At the beginning, we will have the early infection where what happens first is the viral response. Here, the patients may show mild constitutional symptoms, especially fever, dry cough, diarrhea, and headache, also anosmia in some cases.

And the analytics, they show lymphopenia, increased protuberant time, increased d-dimer, and also lactate dehydralgiase. We also know that some patients might be asymptomatic in this phase and not exhibit any symptoms and do not have a detrimental evolution of the disease. But some of them just progress to the pulmonary phase.

And here, we also have the response, the host inflammatory response. In these cases, we are going to see shortness of breath, hypoxia. We also are able to just have this abnormal chest imaging, an increase in transaminases, and a low to normal calcitonin level.

And if the host inflammatory response is really exaggerated, we just come to the third and final stage where we have this hyperinflammation, where we have just this similar symptoms to the acute respiratory distress syndrome. We can also have a shock. We can have cardiac failure.

And we can have, in fact, multiple organ failure because it affects also the kidneys and affects most of the organs. In this case, we have a very elevated inflammatory profile. We will have very increased C-reactive protein, LDH, interleukin-6, the D-dimer, also all markers of cardiovascular, hepatic, and renal damage, and what is known as the cytokine storm.

And in fact, we know that the evolution depends very much on the activation of macrophages. And in these cases, we have an inappropriate adaptive immune response. It has been shown by doing immunophenotyping in these patients affected by COVID-19 that there is a decrease in the total T lymphocyte counts, but also specifically a decrease in CD4 positive and CD8 negative T cells.

And at the end, as I was mentioning, we have all these increased vasculitis and colopathies due to damage in the endothelium. We have increased risk of heart failure. And this deflagrated immune response that really seems to play a very important role in the deterioration of these patients and in the worst outcomes.

In fact, some of the initial studies already showed that the elevation of these biomarkers of cardiovascular, hepatic, and renal damage together with the cytokine storm were really of prognostic value. So you can see in red those that were patients that did not survive as opposed to the blue ones who survived. And you see that from the very beginning, we have a neutrophilic leukocytosis.

And there’s a lymphopenia, which is even earlier and can be seen at the very beginning of the infection. The very high increased edimer, also the C-reactive protein, the interleukin-6, procalcitonin, as I mentioned before, lactate dehydrogenase, also ferritin is increased, and we have also low serum albumin. If we looked at what might be the potential determinants of macrophage activation syndrome, and we know this because of other diseases, like for instance autoimmune diseases, there’s an important genetic predisposition.

And probably this applies also to the COVID-19 infection. For instance, there might be a genetic predisposition based on differences in the ACE2 receptor, or there might be differences in the cytolytic response pathway. We know that another important determinant is the background inflammatory activity.

This is something that is very familiar to us in obesity, where we have chronic meta-inflammation with increased inflammatory cytokines and also an altered response. There are determinants that are also trigger specific, and there might be differences in how the coronavirus affects people, and also if the same coronaviruses are changing in different countries, in different places, if there might be mutations that may just determine the different death rate, but also the different infectiveness of the different strains of the virus. And finally, all of them all together just provoke this increased macrophage activation and expansion with the cytokine storm that I mentioned before.

And this is not new to us, because among the obesity-associated comorbidities, we note that immune dysfunction is something well known. We know that our individuals might be more prone to respiratory infections, and there is also all the evidence related to HINNI1 influenza, but also to the development of septicemia and also of asthma. We know very well that there is an adipose tissue leukocytosis, and we have an inflammasome activation.

We know that there are inflamed veins, and there is a pro-thrombotic state. We have an insulin resistance. We have all these atherosclerotic features, which obviously just make our patients more susceptible to the infection.

What has been known so far is that the coronavirus, yes, one of its structural proteins, the spike, the S-protein, is primed by a serine protease that is a transmembrane. This is needed for the interaction of the virus with the ACE2 membrane-bound receptor. Once this interaction takes place, what happens is that ACE2 is internalized and also downregulated with the viral entry.

ACE2 is the angiotensin-converging enzyme 2, and we know that what it does is just to cleave angiotensin 2 to just produce angiotensin 1 to 7. In normal conditions, angiotensin 1 to 7 just interacts with the mass receptor, and it exerts all the beneficial effects that we know that are related to being anti-hypertrophic, anti-fibrotic. It also leads to vasodilation and has also anti-oxidative effects. Due to the infection, what happens is that ACE2 is internalized, so it’s no longer going to be available, or at least in those quantities, to produce this conversion of this cleavage to angiotensin 1 to 7. Here we will have a shift so that what will predominate will be the effect of the angiotensin 2 and 81 receptor, which we know has these detrimental effects, which is vasoconstriction, cell proliferation, hypertrophy, and also fibrosis.

Altogether, what we will have is not only in the lungs, but also this takes place in all of the tissues, and we will have an increase of the effects of angiotensin 2, which we know are related to an increased inflammation, to increase reactive oxygen species, to vasoconstriction, and also to an increased thrombosis, which we know leads to endothelial damage. This is happening in all tissues, and it needs to be taken into account that after the respiratory system infection, there is an extra pulmonary organ spread, and the virus just leads to different tissues, and adipose tissue in particular expresses ACE2, and in particular in people with obesity, there is an increased expression of ACE2. This is going to lead to the immune system preactivation, and the adipose tissue can work as an adipose tissue reservoir for viral shedding, but also for immune activation, cytokine amplification, and systemic tissue injury.

Furthermore, Kruplikov and Philip Scherer has proposed that in a similar way to what happens to the adipomyocyte switch that takes place in adipose tissue, where we have myofibroblasts that can be transdifferentiated, what may happen in people infected with COVID-19 that are obese is that we have lipofibroblasts that are going also to transdifferentiate to myofibroblasts, and yes, contribute to the idiopathic pulmonary fibrosis that we see in those patients. So, taken together, some of the multiple pathways by which obesity and also excess ectopic fat may lead to an increased severity from COVID-19 infection can be put forward. For instance, we know there are effects on the lungs, but these are not only mechanical effects where we have a decreased ventilation and a decreased diaphragm contractility.

We also know that there is tissue damage to the pneumocytes where we are going to have all these pulmonary edema. We are going also to have yaleen membranes and some fibrosis and an inflammatory response. We will also see cardiorenal stress and increased blood pressure, increased thrombogenic potential together with metabolic alterations like diabetes, and all of them just collide to a lower cardiorespiratory and metabolic reserve that is going to increase the cardiovascular susceptibility to the immune driven vascular effects and proteombotic effects.

On the other side, we have this dysregulated hyperimmune response, probably mediated or at least in part mediated by excess adiposity, excess dysfunctional adiposity, which is common in obesity. There might be also an increased viral shedding and increased viral load in the breath of our patients with a dysfunctional immune response and increased viral exposure. All of them, all these paths, yes, having as a confluence a worse outcome in our patients with COVID-19 infection.

Just looking at the future, I would like to, yes, draw your attention to not only what we know, the acute COVID-19 infections curves, because all efforts now for policy makers, for politicians, but also for health professionals, is the need to flatten this very first curve. For those, many strict rules have been put in place, but it will be equally important to know and to be aware that there are going to be other curves. These are subsequent health-related curves.

For instance, all the delays in urgent care and lack of guidance-directed care for many of our patients. Non-urgent procedures have been postponed. For instance, bariatric surgery has been postponed.

Many appointments have been cancelled or at least they are on hold. Obviously, this is going to have an effect on patients living with obesity. There might be also rebounds of the COVID-19 infections, so we need to be aware of that.

But I would like to just draw special attention to the fourth curve, which is that of the neglected chronic conditions. And here, overweight and obesity really are very important, because we can just think what might have happened to this initial curve if we would not have had such an obesity pandemic. But also, we need to think what will happen if we do not care for these patients in the long term.

The last curve that is depicted in this very interesting slide is the mental and health economic burden, which also impinges on people living with obesity. So to finalize, I would like to just conclude that between COVID-19 and obesity, there is more than a coexistence, because there is really multiple points of impact of the two diseases. People living with obesity have an increased risk to develop the infection, but also once they develop the infection, they have a worse clinical course with more complications.

This can lead to increased risk of hospitalization, but also to increased risk of having to end up in an intensive care unit, and even an increased risk of death. So there is a need or really the urge to raise awareness in people living with obesity for very good and appropriate diagnosis. Also, how to manage treatment and how to deal with prevention in this very specific population.

I will not comment on the additional effects during the lockdown phase that our president already mentioned at the beginning, but that will be also very important to take into consideration. So that’s all from me. I just leave the screen to you.

Thank you very much, Hema. That was a fantastic presentation. We will have a question and answer session after the next presenter.

So I see that Professor Barbara McGowan is sharing her screen already. For any attendees who arrived after the very first slide of introduction, if you would like to ask a question, please do so using the Q&A function at the bottom of the screen. There’s a control panel at the bottom of the screen that you can use.

We will not be using the chat function today, but the Q&A function. So it now gives me great pleasure to introduce Professor Barbara McGowan, who is a consultant in diabetes and endocrinology at Guy’s and St. Thomas NHS Foundation Trust in London, United Kingdom. We’re lucky to have her today talk about the third player diabetes.

So I hand the virtual floor to you for your presentation now, Barbara. Thank you. Thank you, Ian.

Can you hear me? Perfectly well, thank you. Fantastic. Well, thank you very much for inviting me to this webinar and thank you to our listeners for joining in.

So today I’m going to talk about the third player, that’s diabetes within the context of COVID-19. And what I will do is give you a little bit of an overview of the published data on the incidence, severity and mortality, and then touch a little bit upon possible mechanistic behaviours of the virus, although Professor Fulvik has done an excellent job already. So I won’t be going too much into that.

So first of all, what we have is history. We do know that there are poor outcomes of viral infections associated with diabetes. So if we go back to 2003 and look at the severe acute respiratory syndrome data or SARS, there was a poor outcome of death, ICU admissions and mechanical ventilation, which was at least three times higher in patients with diabetes compared to patients without diabetes.

And hyperglycemia and diabetes were independent predictors of mortality and morbidity in patients with diabetes. If we then move on to 2009 and look at influenza A or H1N1, again, the odds ratio for ICU admission was at least four times higher amongst hospital patients with diabetes compared to those without diabetes. And finally, if we move on to 2012, at the Middle East Respiratory Syndrome or MERS, again, a systematic analysis of over 600 cases suggested the diabetes was prevalent in approximately 50% of patients.

And again, the odds ratio of developing a severe or lethal disease following a MERS COVID infection in patients with diabetes ranged from two and a half to roughly seven times greater. So we have history here. So if we look again at the comorbidities, which Professor Fruberg has already alluded to, we can see that this is US data and we can see that obesity features very highly, nearly at 50% alongside hypertension in patients with COVID-19 hospitalization.

And diabetes is about the fourth, at least according to US data, alongside chronic lung disease and cardiovascular disease. But what’s really interesting again, and again, Professor Fruberg has alluded to this, if we look at the age range of patients with COVID and we have in the light blue, the young patients, 18 to 49, and then in the dark blue, 50 to 64 years, and in the dark gray, the over 65 patients, what we can see clearly that with obesity, the majority of patients are younger, as you can see, compared to the rest of the comorbidities or complications, which clearly increase with age. So hypertension, cardiovascular disease, and to a lesser extent, nevertheless, an increased proportion of people in the older population.

So let’s look at diabetes and ask the first question. So is there a susceptibility to SARS or COVID-19 in patients with diabetes? And actually the Chinese data seem to suggest that the overall prevalence is not really different. So if we look, you can see that the overall prevalence of diabetes in the adult population in China is about 10.9%. And we look at the various studies, this incidence is about the same as a couple of smaller studies suggesting a higher incidence.

But if we look at the one study, that’s the second in the graph, you can see a proportion of around 7.4%. And indeed, if we look at US data, where the prevalence of diabetes is about 13% in the adult population, CDC data suggests the prevalence of 10.9%. And in Italy, in Padova, we have a prevalence of around 8.9% in one of those studies, which compares to about 11% prevalence of diabetes from the same region. So whilst it doesn’t seem to be perhaps an increased incidence, what we do know very clearly is the severity is greater. So the proportion of people with diabetes is higher among patients with severe COVID-19 symptoms, and by severe, I mean patients with ICU admissions.

And this is Chinese data again. And if we perhaps look at the one data, which is the largest one with an N of over 1000, we can see that the severity is 16.2% versus 5.7% in non-severe cases. And if we then look at the US data against CDC data for COVID-19, this suggests that only 6% of patients with diabetes are non-hospitalized versus 24% of patients with diabetes who are hospitalized but not going to ITU, and 32% of patients with diabetes hospitalized in ICU.

So moving on to mortality, again, there seems to be a prevalence of non-survivors in people with diabetes. So this is Chinese data. And as you can see here, you have an increased mortality in, as you can see from the one data, 26.9% versus 6.1% of survivors.

And if I show you then the Italian data again, what we have here is in Italy, the case fatality rate was about 35% of patients or people with diabetes versus an overall fatality rate of about 7%. And if we compare this to the New York state, where diabetes was present in about 37% of patients who died from COVID-19. So fairly substantial figures.

What is really interesting is actually that there seems to be higher mortality in people with diabetes or uncontrolled hyperglycemia versus patients or people with no diabetes or uncontrolled hyperglycemia. And this is a US retrospective study, which shows that patients with uncontrolled hyperglycemia or diabetes, and actually say that hyperglycemia was defined as at least a few blood glucoses over 180 milligrams per deciliter or 10 millimoles per liter within a 24-hour period with an HbA1c of less than 6.5%, i.e. no diabetes or people that had not been tested with an HbA1c test. So we can see that diabetes or uncontrolled hyperglycemia has a mortality rate of nearly 29% versus 6.2% with no diabetes or uncontrolled hyperglycemia.

And what’s really interesting within this cohort is actually the mortality was higher in people with uncontrolled hyperglycemia without known diabetes versus patients with diabetes, suggesting perhaps a stress hyperglycemia is a risk factor. And of course, we know this from our experience of stress hyperglycemia associated with a poorer outcome in patients admitted with myocardial infarctions. A very recent paper in Cell Metabolism again makes this point and shows a higher mortality, this is Chinese data, in people with uncontrolled blood glucoses.

Good control was defined as a glucose of 3.9 to 10 or 70 to 180 milligrams per deciliter. And again, what we can see in this Kaplan-Meier plot is that the well-controlled had a greater survival versus patients with poorly controlled diabetes. Now, let’s think about some general considerations and potential mechanisms of why diabetes is associated with a worst outcome.

Well, we all know that type 2 diabetes is a chronic inflammatory condition and hyperglycemia and to some extent insulin resistance promotes an inflammatory state through the production of inflammatory cytokines, oxidative stress, and other additional molecules that mediate tissue inflammation. We also know that hyperglycemia is associated with several defects in immunity, so inhibition of lymphocyte, proliferative response, impaired monocyte and macrophage, and neutrophil function, which again Professor Fubuck described very eloquently. And there’s also some evidence to suggest that hyperglycemia increases influenza virus infection and replication in vitro in pulmonary epithelial cells, suggesting perhaps that it may also enhance replication in vivo, although we need more studies to confirm this.

Now, Professor Fubuck described really the direct endocrine link between diabetes and COVID-19 through the role of ACE2 enzyme, so I’m not going to dwell too much on this, but really to emphasize the fact that expression of ACE2 also takes place on pancreatic beta cells and this may allow entry of the virus into islet cells and cause acute beta cell dysfunction, which we do see very commonly with patients presenting with hyperglycemia and ketosis and severe ketosis sometimes in our cases of COVID-19 and certainly we’ve been experiencing this in London. She of course went through the balance between the angiotensin 2 and angiotensin 1 to 7 and of course we can speculate of course that the ACE2 plays an important role in the severity of the disease and the disbalance between angiotensin 2 and angiotensin 1 to 7 will probably play an important role in severity. So in summary, diabetes is one of the most frequent comorbidities in COVID-19 patients.

It promotes severe progression and leads to higher hospitalization and ICU admission. What we also know is that diabetes increases mortality in patients with COVID-19 and preliminary data suggests that hyperglycemia is a risk factor and we should think about safely ensure that it is treated, although we will need to carry out the clinical trials to assess whether managing hyperglycemia in the acute setting at least makes a difference to outcomes. And of course we need more studies to define the interaction between diabetes, obesity and COVID-19 and understand the mechanisms involved.

So with that I will stop and hand over to Euan. Thank you. Thank you very much Barbara, that was another fantastic presentation.

This leads us into a short Q&A session. We have received a high number of questions via the Q&A functionality and so we will try to ask them to yourself, to Hema and any of the other panellists who may wish to contribute to answering these questions before we move to the next part of the presentation. So a couple of questions are overlapping in a sense and some people have asked, is there any evidence that obesity causes an increase in the rate of infection as opposed to the rate of severity of COVID-19? So are people with obesity at higher risk of becoming infected? I think from the published data so far, I think that obesity is probably, like diabetes, I’m not sure there is an increased incidence in patients with obesity, but the severity and the mortality is higher in patients with obesity from the data I’ve seen so far.

But you know Hema might disagree with me on this, but I’m not sure that obesity itself predisposes you to an increased risk of infection. But if you do actually get the infection, you’re likely to have a more severe cause. Yes, from a mechanistic point of view, it might be the case.

So if you look at what we’ve been presenting, there might be this situation. The problem is that it’s very difficult to disentangle what is the real contribution of obesity, of type 2 diabetes, of the different aspects that probably impinge all together. And it’s important also to mention that in many countries it’s difficult to just record BMI.

For instance, in Spain, there was such an overload of all the emergency departments and of all hospitals that to us to look at BMI was just really like wanting them to do an extraordinary work when the situation was really chaotic in some cases. But I think we need to continue studying the situation and probably Dror and Luca might want to add something to that. I have a little comment about that.

I mostly agree with Barbara that probably obesity and diabetes are more important in determining the severity of the disease than the infection rate. In any case, at the moment, I think that we cannot say anything about the infection rate because our data are limited to the small fraction of the population that has been tested with a swab. So in order to answer this question, we need to have more general data about the spread of the virus in the general population.

And this can be obtained only through serologic studies, not concentrated on people having the disease. Okay, thank you very much to everybody. We have a couple more, we have a few more minutes where we can ask some questions and another one might relate to the actual status of obesity.

When we talk about obesity, do we refer to uncontrolled obesity or do the risk factors also apply to those with controlled obesity? For example, bariatric patients who are responding well to treatment or is there a differentiation? I think that we have to define what is obesity. I think the most important thing is that if you have or not dysfunctional fat. So if after bariatric surgery, your fat adipose tissue is healthy, so I imagine that your risk is lower and you still have dysfunctional fat, meaning that you have high glucose level, high triglyceride, low HDL.

So the risk is higher. So the issue is not the BMI or the weight, the issue is if you have dysfunctional fat, if you have insulin resistance and if you have low grade inflammation as Gamma showed. This is my point.

Yeah, I fully agree with Yeah, this is another way of showing that we need to go beyond BMI as EASO is always fighting for. Yes, exactly. Exactly.

Okay, we have time for a few more questions, but I’d just like to remind the audience that we will group the questions after the webinar and try to answer them in some kind of a document that we will share on the EASO website because the volume of questions is very encouraging, but also quite difficult to respond to. But we do have time for a couple more questions. I’m going to ask my colleague Cherie to ask the next one because I think she has one ready.

Thank you. So we’ve got a couple of good questions, which are somewhat related. Following up on the question around people with obesity being more prone to risk of COVID-19, bariatric patients tend to have weakened immune systems and might this make them more susceptible to contracting COVID-19? And that question is from the Executive Director of the European Coalition for People Living with Obesity.

Well, as far as I know, we do not have data on patients that have undergone bariatric surgery and the relation to COVID-19 infection. So it will be very interesting really to study that in more depth because it’s a very good question. So maybe we can have a little shot here about the situation where we have operated patients just before the outbreak that were asymptomatic, that nobody knows that they were carrying the virus, but they were operated.

This is a disaster. We have now at least two publications that describe this situation where asymptomatic unknown COVID-19 patients were operated. Death rate is 20%, severe complications 40%.

Ventilating for three hours during a surgery, someone with virus there is a very bad situation. So this is mandatory that when we start now again, that we’ll screen very carefully every patient before we go to surgery, even if things seem to be better. A little bit the way we do with a beta hCG in young women just to avoid the stupid situation of having someone pregnant, you just operated last week and you didn’t know.

This is something we have to be aware of. We should not be operating someone with COVID asymptomatic. Also to relate to the medication.

So we had several post-bariatric surgery patients, which all of them had a non-severe situation, meaning mild, maximum moderate. But the issue was what is the treatment or if there is effect of the bariatric surgery on the medication, especially on lacuanil or hydrochloroquine and azanil and zinc. So we found in the literature that bariatric surgery is affecting, especially the bypass affecting the dosage of chloroquine and azanil and we have to adjust the dosage for those people.

So post-bariatric surgery, if you are decided to give this combination, you should adjust the dosage after bariatric surgery. Okay. Thank you very much for all these contributions.

There are still a lot of questions which we might be able to address in the Q&A session after the country presentations, but in an attempt to adhere at least loosely to the timeline and the agenda, I’d like to move on and ask our next presenter to present for us. So we are lucky to have Francois Poitou, Professor Francois Poitou from the Anselm University, Lille, Lille Pasteur Institute in Lille, France. And he is going to tell us about some very interesting experience in France and particularly in his area within France.

So Francois, I leave, I open the virtual floor to you if you could click the normal presentation button and then the floor is yours. Thank you. Okay.

Thank you very much. Everyone is it okay? Do you see correctly and hear me correctly? Fine. Okay.

Well, thank you very much for the opportunity to present you these data and to give you a French snapshot that was the title I was asked to talk about. So here is a snapshot. So in France, things have started a little bit later than in Italy, two or three weeks beyond.

There are some discussion about some early case before Christmas, but this is not documented. The first cases started in France in Paris, late June, late January. So you have on the left, this classical curve that is everywhere seen with the number of admission that are now decreasing hopefully, but the number of deaths have been very astonishingly high.

25,000 people have died already and more than 90,000 patients were hospitalized for COVID-19 so far in France. And you have here the distribution and you can see that there is clusters, clusters of the disease. It’s not spread out everywhere in France and we know that there is clusters because of infection, but this is a strange picture I would like to share with you, the double pain.

So this is on the middle, the map of the de-confinement officially released yesterday. That will be for the next Monday, the official rule. So the red departments are the periods, the region in France that are supposedly high pressure for COVID.

And this is not so far for the circulation of the virus in instance of a positive screening, but more of the occupancy rate of the intensive care units, which is worrisome in some of these departments. So the sum of these two points, I’ve made this map, which is quite worrisome for those who are living there. We are living here, so this is worrisome for us.

But this is, look at this, our map is prevalence of obesity in France. The darker, the more prevalent obesity is. 25 person in my region, the North of France, which is the most prevalent region.

And you can see that the darkness is quite similar and that’s quite amazing to see that. And especially when you look at this intensive care occupancy rate. And that’s just the specific story we just went through.

So my university hospital is a huge, just a referral center for 4 million people. So it’s 3000 beds. So everything seems big there.

And of course we had admission for COVID patient in ICU. That started for us late February. So a little bit after the East and the region in Paris.

But of course, like everywhere, the striking thing was the number of patients admitted to intensive care. But more than anything, the friend of mine who is in charge in intensive care just warned me very early that these patients are strange. We are not used to these very heavy patients.

And you have seen this picture of people ventilated on the belly because this is the way they have to do. So very astonished by this high frequency of obesity, went with them and tried to have the numbers because it was impossible at that time, we are in March or late March, to have BMI in the literature. No Chinese series, the first big Italian series in the JAMA did not capture BMI.

So we didn’t know. So that was astonishing. So we checked and we had these 124 patients admitted, the first one admitted in Lille, consecutively in intensive care with SARS.

And we compared them with 300 patients that were admitted the year before, before SARS started in the same departments. And this was astonishing. This is on the left, the exact distribution of obesity in our region, which is 25% obesity.

And here it was double the number. And in fact, nearly the vast majority, more than 80% of patients with this wave of intensive care were with overweight or obesity. Half of them were obese.

That was very astonishingly expected. Then patients with severe pneumonia, because that was very some of these colleagues that they were in trouble to deal with these patients with a lot of mortality. And one thing was the requirement for invasive mechanical ventilation.

So this readout was chosen because it’s a robust proxy for severity. Death, of course, is the ultimate proxy, but the thing is death is really mostly age is driving death in this population. So when we are looking at invasive mechanical ventilation, we’re really looking at the severity of the pneumonia.

And so here again, you can see that those patients who had needed ventilation were more obese again. And so this is another way to look at the same data. The disease severity seemed to increase quite incrementally with BMI categories.

So you can see the lean patients, overweight in blue, and obese patient and severely obese patients. And you can see that in the severely obese patients, we represented nearly 25% of the patients, nearly nine out of 10 of them needed invasive mechanical ventilation. That was very striking.

So we then looked at all the characteristics of these patients, the one we could look at. And it was very clear that as previously published, all metabolic syndrome features were more frequent in these patients with severe pneumonia, those that required mechanical ventilation. And you can see that, of course, BMI was there, it was higher.

Diabetes prevalence was higher. Hypertension was also higher. But so it was difficult to decipher what was the distinct weight in this association for every of these parameters.

So we went, of course, because we had the possibility to do it with a multivariate analysis. And once again, you see that even if diabetes can be seen as nearly significant in this multivariate analysis, when we did multivariate analysis, clearly the two factors that still stand as independent association factor with the severity of the disease were male gender, with more than nearly three times more risk for ventilation and BMI categories. And it was patient with severe obesity, the osmosis in this multivariate analysis was nearly seven times.

So that was quite an amazing numbers. So this has been so far confirmed in many places elsewhere. So our friend in Lyon published, just checked their numbers with similar cohort.

And you can see the very, it looks like the same picture. It’s exactly the same distribution. Increase of severity of the disease with BMI categories.

And now in Provida, published And again, these colleagues were able with the multivariate analysis to look together BMI, but also diabetes and hypertension. And once again, exactly as we did, they did not show any significant association with these other metabolic features, but a very strong association with the BMI, especially with the severe obesity category. And once again, look at the numbers, odds ratio is six, very near to our number.

This is the table ITU admission, but they also have a table for ventilation. So with the same numbers as we just showed. So once again, it seems to be quite robust and reproducible elsewhere.

So if we now look at what it did give in France, that in the end of with all this, and this is the group for research and obesity force led by Martin Lavier and the Afero. He is the president, the association, the French speaking association for obesity. All these folks together joined effort to convince the government to take, to take notice of that.

And we were happy to all together obtain that in late April, is the new guidelines that changed the initial ones to consider that anyone in situation of obesity with a BMI above 30 should be considered as vulnerable in this pandemic and should have specific measures in terms of protection, but also of treatment in future straight, but are coming or testing for the next wave. So testing should be mandatory or at least for this specific category of patients. So this is the take home message in France.

These are the, that obesity is a significant risk and should be considered as so. So thank you for your attention. And any, any question is, this is my colleague in ICU who take care of all the, all the, the patients and hopefully next year, we’ll be able to have our spring research day with patients.

But this year, of course, this is canceled and we are hardly trying to find a way of explaining this obesity link. Thank you very much. Thank you very much.

Yes, we would hope for that next spring as well. Of course, we have a Q&A session at the end of these three country presentations. So we will open questions at that point.

And so obviously we can’t physically do this, but we can virtually travel from France to Italy now. And we can hear the experiences from Professor Luca Becetto from the Padova University Hospital. So we shall, we shall hand the virtual floor to Luca.

I give you the floor Luca. Thank you Juan. Thank you Juan.

I will be very happy to travel to France. I will be very happy to travel everywhere now because we are so confined in Italy, but the situation is getting better for us. And good afternoon to everybody.

I will share with you some consideration about the general situation in Italy and some still unpublished data that we have collected in our hospital during the last months. As you know, Italy was the first European country to face the outbreak. We had the first case in late February without known exposure to China or to other foreign infection.

And since then the situation was really getting worse. And these are the official data from the National Institute of Health adjourned to the 5th of May. The official number of confirmed cases in Italy is over 200,000.

And we are at the moment very close to 30,000 of them. As you know, most of these cases are concentrated in the north of Italy, especially in the Lombardy, the region of Milan and surrounding cities and the surrounding regions. And I work in Veneto, that is northeast of Italy, very close to Lombardy with Venice as the capital city.

And these are the official data from our regional health service adjourned to the 5th of May. In our region, Veneto is a region with about 5 million inhabitants. We are very close to 20,000 confirmed cases.

And we had 100, 500 deaths, including also some people not dying in the hospital. Because as you know, in Italy, like in many other countries, there is by sure an underestimation of the death because their official numbers, both at the national and the regional level, are mostly based on deaths registered in hospitals. We have all the problems with the deaths in the nursing homes and at home that we are not counting officially so far.

This epidemic in Veneto caused a very rapid increase in hospitalization in our region, starting from the first days of March and peaking in the 1st of April, when we had 2,000 patients in hospitalized for COVID in our region. My hospital is one of the largest hospitals in the region. It is a teaching hospital located in Padova.

At the beginning of the epidemic, the hospital tried to cover the needs with the intensive care units. We have a very active, semi-intensive respiratory unit, with thermologists. And we have a special infection disease unit.

But during the rapid peak of the curve of hospitalization, our hospital reacted by increasing the number of ICUs, but also transforming some of the internal medicine units in COVID, internal medicine units, in which we can hospitalize patients with no need for intensive regulation. So, at the peak of the epidemic, the systems work in a huge way, with four units entirely dedicated to COVID patients. My unit, my internal medicine department, was the COVID plus one.

And we had a continuous exchange of patients, obviously, according to the need for more intensive care. And at the end, most of the patients were discharged at home or in small community hospitals, dedicated community hospitals, mainly through our department for the infection disease. So, during a month of experience with COVID, very direct experience with COVID-19 in our medical world, I was able, with my colleagues, to collect some data about our patients.

These are still partial data, still unpublished. But I am like, I like to share with you this initial data because I think they are interesting in the topics we are living today. So, this is the distribution of the BMI class in our population.

And as Francois saw for the French mutation, we are clearly an over-representation of overweight and particularly obesity as compared to the general able population in our region. One additional thing that I like to emphasize is that the age, the mean age of patients with overweight or obesity, it was 10 years less than the mean age of the patients with normal weight. And this is, this could be a sign that patients with overweight and obesity require hospitalization at a younger age as compared to normal weight patients.

Our hospital, our work asked mostly patients with no need for intensive ventilation or intensive ventilatory support or advanced ventilation. But of course, some of the patients develop this need during hospitalization. And these are the percentage of patients requiring most intensive form of ventilatory support during the stay.

And again, the patients with overweight and obesity show a higher need for more intensive ventilatory support as compared to the patients with normal weight. The death rate at the company was clearly higher in the normal weight class. And this is mostly driven by the fact that in this class, we had a lot of patients with very advanced age, dementia, advanced cancer, in which the transfer to more intensive care units was deemed not appropriate based on patient general condition.

So we need to take into account the possibility that the data about ventilation could be in our sample, normal weight patients could be underestimated by the fact that there are some patients in which we choose not to perform more advanced ventilation. But we repeat our analysis by excluding those patients with dementia and cancer, and still, in particular for non-invasive ventilation, we observe a higher rate of this form of ventilatory support in patients with overweight and obesity as compared to normal weight patients. These are our small data and the general messages are that overweight and obesity were frequent in a cohort of patients admitted to an internal medicine ward dedicated to the care of COVID in our region.

The patients with overweight and obesity were 10 years younger than patients with normal weight. Patients with overweight and obesity, despite their younger age, require more frequently advanced ventilatory support. They are more prone to be admitted to intensive and intensive care units.

And this difference was maintained even if we concentrate our attention only in patients without dementia and cancer. These are the data. This picture is more a personal impression or a description of the two more frequent phenotypes of patients that I saw in my work during these months.

By short, we have a lot of frail, elderly patients with comorbidities, dementia, cancer, low BMI, probably a sign of frailty in this case. And these are the group of patients that normally die, of course. You know that more than 50% of the deaths in Italy are in patients with more than eight years old.

But the second phenotype is like this one. I choose this picture. Maybe you know this man.

This man is a writer from Chile that died during the COVID epidemic in Spain. And the second most frequent phenotype in our hospital is this one. A man, middle-aged man, with overweight, obesity, mostly concentrates in the abdominal region, probably with metabolic complications like other speakers underlined during these topics.

So these are the Italian snapshots. So I will be very curious now to learn about the Israeli snapshot. And I thank you for your attention.

This is a very direct experience. And I hope that you appreciate this presentation. Thank you so much.

And I stop myself. Thank you very much, Luca. It was excellent to hear this update from Italy and also to hear some, at least, story of a positive direction.

So we move now to the last formal presentation of the day, of the webinar, to hear about what is happening in Israel. And for that, we have invited Professor Dror Dicker. He’s the head of the Internal Medicine Obesity Clinic at the Hasharon Hospital in the Rabin Medical Center in Israel.

He’s also the co-chair with Luca Bassetto of the IASO Obesity Management Task Force. And so we hand this virtual floor to you now, Dror, to give us the Israeli snapshot, please. Okay.

Good afternoon. Thank you for the privilege and the honor. Do you hear me? Perfectly well.

Thank you. Great. So the COVID-19 epidemic start in Israel in the beginning of March.

And we can see here the total number until yesterday, that around 16,000 patients. But we can also see a very optimistic diagram that the epidemic reached the peak in the end of March. And since then, there is decrease of patients around the country.

Yesterday, we had only 43. So this is very optimistic that maybe the epidemic is going to finish very closely. So we had the opportunity to see the numbers of Israel in comparison to all the world.

And we are I think in a very good situation. If you take the number per 1 million citizens, we are in the lowest number that you can see comparing all other country in the world, and especially in Europe. And this is maybe the very early lockdown and the isolation of Israel from flights from other countries that we had, and maybe for other reasons that I will share with you.

What we learned until now that if you look into gender, you can see that in men, the peak is around the 50 to 70 compared to women. The light blue is the percentage of men. The dark blue is the percentage of men that were intubated that need to a mechanical ventilation.

But what very interesting is in the age of 70 to more than 85, we can see that women are much more prevalent than men, and much more tend to be intubated compared to men. If we take the percentage of all men and women, we can see again that the most prevalent age group that had COVID-19 is the very young age, but the more severe disease is of course in the elderly and in men elderly. Now, we had more than 16,000 improved cases.

We had 239 deaths, which is very low. And until now we had in home isolation, 190,000 patients. And still now we have 244 patients in hospital right now, and in the hotels, 1,400.

More than 10,000, nearly 11,000 are now discharged and are healthy from the disease. So I think one of the reasons that we had lower mortality and lower incidence of disease is the system that Israel is using. So if the patient has proven for COVID-19 or proven for SARS, if it’s a mild disease, we isolate the patients in special hotels.

If it’s a mild disease, but the patient is elderly and need a geriatric institute, we send them again to a special institute for isolation, those elderly geriatric patients. And from then from the hotels and from the geriatric institute, they are sending home after they cleared the virus from the throat. If they are in moderate situation, meaning they are shortness of breath, low in percentage of oxygen, so they are sent to the hospital.

But different from all other countries in Europe, we have internal medicine that is very strong, meaning that we are intubated. We are treating mechanical ventilated patients all year in the internal medicine department. Around four to eight patients are treated by mechanical ventilation all year in the internal medicine department.

So the patients in the moderate and severe situation of COVID-19 were admitted in special isolated internal medicine department and were treated in the internal medicine department. Only those that were very critical in very critical situation need ICU moved to the ICU. And by doing so, we really protected the ICU from floods of very severe patients.

So the system is that internal medicine in Israel protected the ICU from crash. Of course, when the COVID-19 patient recovered, they were sent home. And from the ICU, they sent to rehabilitation center, special rehabilitation center.

So I think the system that in all year are really working in a very intense way in the COVID-19 epidemic really worked very good. The second thing is that we had to get used to total different system of treating patients. We used a lot telemedicine.

And here you see me treating the patient through screens. So it’s for internees, it’s not so easy to get used to treat patients through screens and not to touch them and to speak them, to see the eyes and to see really how they behave. We also had to really treat ventilated patient through screens.

And if we needed, we get into the department and treat the patient. Of course, the first thing that we really take care is to protect the staff from being infected because we are in everywhere, we are short in staff. And by doing a telemedicine, we try to really protect the patient, the staff.

So if we take all the data regarding BMI in my department, we had total 112 patients and 24% of them had obesity, meaning BMI above 30. The moderate patients increased 30%, meaning the obese prevalence increased to 30%. The severe patients around 30% and the intubated patient around 25%.

If we compare it to 24,000 patients that we published very recently, we see that the percentage of non-diabetic patients in this regard of obesity is less than what I showed you before. And if they had diabetes, again, the percentage are less than what we expected now and what we showed now in the COVID-19 epidemic, meaning that obesity in those patients is much more prevalent than the everyday treatment of internal medicine patients. The other issue is when to discharge the patients from the isolation department, because it can take a long time until you clear the virus from your throat.

And from the H1N1, we can see that an obese patient cleared the virus much later than the lean patient. So we wanted to examine this, and this is unpublished data. We compare 34 patients, 22 were men and 12 were women.

And again, we can see the percentage that 41 had hypertension, the women had 33. 22% of diabetes, the women had 33, the same as you showed before. And what we showed here, that regarding the BMI, the higher the BMI, the later the clearance of the viral load from the throat, from the swab, meaning that prolonged disease in the obese patient, and this is very important regarding the obese patient, had a longer period of virus in the throat.

Why is this? We heard before the two excellent lectures, and this is two slides from genome research that showed that adipose tissue had higher ACE2 receptors in the tissue. This is one study, and this is the second study. Even in the subcutaneous, there’s higher prevalence of ACE2 receptor, and of course, in the visceral adiposity, meaning if you have higher prevalence of ACE2 receptors, you have higher port of entry to the virus into the adipose tissue.

And then maybe it’s the explanation why obese patients or people with obesity clear much longer the virus from the body. So my take-home message is that obesity is a major risk factor of increased morbidity and mortality from SARS-CoV-2. The viral load in people with obesity may be higher due to higher expression of ACE2 receptor in the adipose tissue.

Hence, clearance of the virus can take longer, and social distancing should be longer. This is very important, I think, notion. People with obesity should be prioritized regarding vaccination, early treatment, and early hospital admission if needed.

And we should be more aware and careful regarding people with obesity stigmatization in the COVID-19 times. And this is my take-home, all the protection that I needed. So thank you.

Thank you very much, Dror. That was another wonderful presentation covering a lot of important points that had been raised within some of the questions submitted through the Q&A function. Very, very interesting indeed.

We are a little over time, but I think we certainly have the opportunity to have some further discussion and some questioning. And one of the themes of the questions has been around a fear within the patient community. Is there an increased risk of should people with obesity go early to the hospital? How do we communicate with people with obesity without increasing fear and increasing panic? And how are people managing virtual clinics? How can people with obesity who are not affected by COVID-19 in any way, how do they access their treatment and how do they access their clinics? Now, that’s quite a general set of questions, but it all relates to the fears that we’re seeing and the questions that we’re seeing within our patient community colleagues.

So I wonder if the panel could address some of those issues for the patient community for us. Yes. So, Ewan, I want to stress the reason that we did this study is because to my humble opinion, the most important treatment for the COVID-19 pandemic is to get early to the hospital.

If you get early enough to the hospital, we had the experience and we had the knowledge how to manage the disease. If the patients arrive to the hospital in the cytokine storm, it’s very hard to treat them and to cure them. If they are getting in the viral stage, we can really treat them, cure them and discharge them.

So I think for me, the most important lesson is that obese patients are in increased risk. They should come to the hospital as soon as they have the disease that need hospital treatment. This is my message.

Thank you, Dror. Any other panelists care to comment further on those responses? Yes, this is Hema. I would like to say that what Dror mentioned is very important, but for those patients that don’t have COVID-19 infection, it’s also important just if they need the medical support, if they need adjustment of their medication or if they have questions or they would like to share their doubts or their fears with the physicians, either to do a video consultation.

We started that very early on in our department and it worked very nicely. For all nutritional issues, it worked perfectly. Obviously, you are not able to do an exploration, physical exploration, but at least you’re able to support the patient.

Also, in our hospital, at least, we are doing different circuits. There is a COVID-19 circuit and there is also a COVID-19 free circuit so that depending on the situation, they are separate and the professionals working in them are also different. It’s important to encourage our patients to ask for help if it’s needed.

Thank you, Hema. I would like to make a comment for the participants that IASO does intend to organise a future webinar on this very topic about how to manage virtual consultation, virtual clinics, how to safely reopen your existing obesity clinics. This would be a future webinar organised by the IASO OMTF and the Network of Collaborating Centres for Obesity Management.

Stay tuned because there will be further discussions on that particular topic. I would like to make a comment, Euan, if we have time. Yes, please do.

Regarding teleconsultation, I’ve done quite a lot of consultation with families, parents and children. I think it was very important for them to have a contact with their physician or with the staff, with the dietician, psychologist, physio. What we did, we organised with the multidisciplinary team teleconsultation together or separately.

The families were extremely happy to be contacted. They could share their fears about the virus, their difficulties of managing the daily life in confinement. I think it’s a very important thing.

Then the difficulties to restart consultation. We are at this stage in Switzerland because we reopened schools on Monday. So next week we restart normal consultation with safety, measure hygiene, distance and separate entrants for non-COVID patients.

Thank you very much, Natalie. That was an important point. Is this happening in other countries? We’ve heard from Israel and Spain, but is this approach to the response to relaxation of the lockdown rules, is this consistent across countries or are other countries taking a different approach to the reintroduction of clinics and to the interaction with existing patients? I mean, in the UK, if I may talk about the UK, we’re still obviously in lockdown and we’re still a few weeks behind everybody else.

Of course, we’ve had a very severe pandemic here. We won’t discuss all the reasons, political or otherwise, for that. But the sad thing is that access to care and some of the obesity care has been absolutely zero.

It’s all very well saying telemedicine, but everybody has been so busy trying to manage the pandemic that really pretty much the rest of the services have been on hold. Not only that, the message to people is do not come to hospital unless you absolutely have to. Then when they do come, they’re probably post the viral stage and into the more severe cytokine storm stage.

But unfortunately, that’s been the UK experience. Having said that, I think it’s absolutely important. Of course, within that, obesity has not really been mentioned at all.

Diabetes, yes, in terms of who we should be shielding, but obesity hasn’t really played a part. I think as we reopen and as we go back to normal, well, not normal life, of course, but whatever the new normality is going to be, this concept of looking after our patients and reintroducing services for our patients is absolutely critical and important. Thank you.

In Italy, in Italy, sorry, Johan. No, no, go on. In Padua, in Italy, we reopened the outpatient services this week.

But of course, we reopened at low numbers than before because I remember my room out of the full of patients during all the morning. Now, this is clearly impossible. So, we restart the outpatient activities, but we need to, anyway, we need to change our way to work with the patients.

And I think that the use of telemedicine that we are forced to use during the lockdown, probably will help us to be more effective also for the future. And maybe at least immediately, this will be one of the few positive legacy of this outbreak, because we are forced to change and to move to alternative way of care. Yeah, that’s a good point too.

Thank you, Luca. Now, we’re quite over time now, and I think it’s a good idea perhaps to wind down the webinar. Would any, would Luca or Natalie like to say some closing words? I have some housekeeping I would say very quickly in that we have recorded this session.

We will be sharing the recording with participants and others. We will be trying to group all of the questions, and especially those that were unanswered, and we’ll try to answer them in some kind of a, an FAQ document so that you can have this information. So, we will follow up with participants and colleagues after the webinar, but I would especially like to thank the panellists for taking the time to contribute.

And I would especially like to thank the many hundreds of attendees who joined and those who asked questions. So, I would, I would ask some of the OMTF and Executive Committee colleagues to say a closing remark, and perhaps we then officially end the webinar. But thank you to all for your participation.

It’s very highly appreciated. Luca, do you want to say? No, Natalie, please close. You are the panellist.

I just would like to thank all the panellists, also the Executive Committee for organising this webinar, and all the attendees. COVID-19 and obesity are definitely important topics to address, and I hope that we will come back with more answers to your question in a few weeks. The research is advancing quickly, hopefully, and also I think it’s important that all centres and researchers work together to get more knowledge about this topic.

So, I wish you a good end of afternoon and also a lot of courage for all countries which are still facing the pandemic. Thank you, Natalie. Thank you, everyone, and to Natalie, especially good luck for the schools returning next week.

Thank you. It’s a big challenge. I will keep you informed.

You’re up to it. Thank you, everyone. Enjoy the rest of the evening, and good luck.

Stay safe and stay strong.

Goodbye. Thank you.

Thanks. Bye.