The parents and two brothers of Silvia Deyanira Melendez, 24, are all in therapy after losing their daughter and sister to COVID-19 on March 28.
"I don’t have the words to say how beautiful and nice to the family she was," her father, Marcos Melendez, said Friday.
She weighed more than 300 pounds with a body mass index of 60, double the BMI considered obese. This most likely contributed heavily to her Type 2 diabetes, hypertension and a heart condition that required open-heart surgery two years ago.
The chronic conditions that increase the risk of serious illness and death of COVID-19 are now well known: diabetes, heart disease, hypertension and being older than 65. Obesity is less well known or understood. The Centers for Disease Control and Prevention groups "severe obesity," defined as having a BMI of 40 or higher, with the other known "risk factors for serious illness" for COVID-19.
CDC data shows the percentage of adults considered obese increased from 30% to 42% between the 1999-2000 period and 2017-2018. Nine percent had severe obesity, up from 5% in 1999-2000.
"Before we had COVID, we had an obesity epidemic going on in the U.S. and we've had this for some time," said Dr. Robert Fildes, a pediatric kidney physician.
The editors of the medical journal Obesity last month said coronavirus created a "dual pandemic threat" and urged health care providers to "take up the cause" of fighting obesity with their patients.
A growing number of studies and data on COVID-19 deaths confirm the link. The extra weight on people in the 40-plus BMI range who contract COVID-19 increases the chance they will require hospitalization, most likely in the intensive care unit. It also hampers the ability of physicians to treat them, especially with ventilators, doctors say.
A study by French researchers in the journal Obesity showed a high frequency of obesity among patients admitted to intensive care with coronavirus. The severity of the disease increased along with BMI.
Along with making mechanical ventilation harder, being severely overweight can make it harder to breathe, reducing the patient's own ventilation, said Dr. Kevin Kavanagh, a Kentucky physician and founder of the patient advocacy group Health Watch USA.
It also reduces the amount of oxygen per breath, so patients have less of a reserve when they get sick.
'It went the other way in a big way'
Marcos Melendez said he was heartened when his daughter seemed to be improving in the hospital, where her mother also was being treated for COVID-19. Melendez had to communicate with both of them by video chat due to to the risks in the hospital and because he and his sons were quarantined at home.
"The coronavirus was making big damage in her lungs and after that, the virus went to her heart," Melendez said. "She was responding good with oxygen and then the virus started attacking her heart. It went the other way in a big way."
Dr. Jeanette Brown, a University of Utah Health pulmonologist who treated Melendez, said the young woman's size prevented Brown and the ICU staff from placing her on her stomach, which is the safest position for patients with breathing tubes hooked up to ventilators. Brown did not identify the patient by name, but Marcos Melendez confirmed it was his daughter.
Placing patients in this position allows doctors to reduce the amount of oxygen needed from the ventilator by allowing patients to use the less-damaged part of the lungs.
When Melendez was on her stomach, her ability to take in oxygen worsened.
So rather than spending up to 17 hours in that position, "we had to flip to her back and try not to lose the airway," Brown said. "She wasn’t even able to tolerate that more a few minutes."
Silvia Deyanira Melendez died about 24 hours later when her heart failed.
"As a provider, you want to help people, but when they are severely obese, the deck is already stacked against you," Brown said.
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Depending on a patient's size, an ultrasound's view is more limited because of the excess tissue. Some of the most obese patients may not even be able to have a CAT scan because the machines have weight limits, Brown said.
"Literally, if they are large enough, you lose some of the tools in your toolbox," she said.
Fildes, who recently retired from his nephrology practice in Washington, D.C., and Northern Virginia, worked with children who had diabetes that would turn into renal disease if they didn't comply with their dietary and glucose guidelines.
Fildes said some of his teenage patients weighed 300 to 400 pounds and some developed high blood pressure as young as 11.
The risk of having a high BMI is so serious that Dr. Talal Munasifi said he and most other plastic surgeons won't perform an elective, cosmetic procedure on patients with BMIs of 35 or higher unless they lose weight. Many surgery centers won't perform even needed medical procedures on people whose BMIs are 40 or higher, he said.
"Once you go over 35, the complication rate gets high," said Munasifi, also on the clinical faculty at MedStar Georgetown University Hospital. The most likely complications are infection and delayed wound healing.
An estimated 75,000 people die a year from infections they developed in health care facilities, according to a 2014 CDC study.
Excess fat cells create other problems, too. They are believed to release inflammatory signals that cause the immune system to overreact to coronavirus, creating something known as cytokine release syndome, according to new research.
Death spurs family to diet, exercise
Brown, who is Mexican American, said obesity and its risks are a familiar topic, personally and professionally. She's been especially worried about her parents, whom she described as obese, during the pandemic because they have Type 2 diabetes.
"The unfortunate thing is we tend to have many of the co-morbidities," Brown said of the Latino population.
She said her parents are eating more carefully now, especially since her father realized he was still eating bread when he had tortillas.
Marcos Melendez said a couple of his friends died recently of COVID-19, and obesity was their only risk factor. He is Peruvian American and his wife is from Costa Rica. Their daughter's loss has made everyone in the family improve their diets and exercise.
"We need to take care of it all," he said.
Since Silvia Melendez's death, the family drinks protein shakes in the morning, doesn't drink sodas and stops eating at 6 p.m., with only water until bedtime. They are "walking and doing a lot of things" recreationally, he said.
Silvia Melendez's mother, also named Silvia, has diabetes and high blood pressure like her daughter. She has continued the diet she started before her hospitalization and has already lost 30 pounds.
After losing his daughter, Melendez couldn't imagine losing his wife.
"I was really scared about her, too," Melendez said. "That virus is very dangerous. It goes after the weakest thing in your body, especially if you are overweight."
O'Donnell, USA TODAY's health policy reporter, is on social media as @JayneODonnell and email at firstname.lastname@example.org
This article originally appeared on USA TODAY: Obesity makes COVID-19 risk larger, hospitals' challenges much harder