Background
The novel coronavirus has rapidly spread to millions of individuals worldwide, resulting in significant morbidity and mortality [
1]. The COVID-19 pandemic has brought about a profound transformation in global health. To address the escalating transmission rates, authorities at the federal, state, and local levels in the U.S. have implemented targeted public health interventions with the aim of controlling the spread of the virus effectively [
2]. The Centers for Disease Control and Prevention estimates that the impact of COVID-19 on the United States corresponds to approximately 1 in every 1.32 COVID-19-related deaths, highlighting the significant burden imposed by the disease [
2].
The potential relationship between weight and COVID-19 incidence has been acknowledged by the scientific community and healthcare professionals. There is a strong association between obesity and a significant increase in the incidence of illness and death related to COVID-19 in individuals [
3]. Obesity is also a major public health concern in the United States, imposing an annual cost of approximately $173 billion on the healthcare system [
4]. In the United States, approximately 30.2% of adult hospitalizations due to COVID-19 were directly attributed to obesity (body mass index ≥30 kg/m
2) [
5]. Additionally, countries with higher BMI levels exhibit elevated rates of both COVID-19 incidence and mortality [
6]. Specifically, a higher body mass index is linked to an increased risk of COVID-19-related hospitalization and death in the United States [
7].
Social participation refers to engaging in activities that involve interacting with others in a society or community [
8], and it has been linked to various health outcomes, including mortality, morbidity, and quality of life [
8]. However, the implementation of social distancing measures during the pandemic, necessary for individual health and safety, poses a challenge to social participation. Consequently, individuals may choose to stay at home and refrain from going out, leading to a decrease in participation in social activities This trend raises new concerns about the complex relationship between health and social interaction. Specifically, previous findings indicated an interplay between social participation and obesity. For example, a systematic literature review provided evidence of the association between social participation and obesity [
9]. Additionally, there was a noticeable increase in sedentary behavior and excessive eating during the lockdown, leading to an imbalance in energy intake and subsequent weight gain [
10]. These findings underscore the critical need to comprehend the dynamic between weight status and social participation during the pandemic.
Globally, having a high BMI (metabolic risk) was associated with death from diabetes and disability-adjusted life years [
11]. However, previous studies have faced limitations in identifying unmeasured variables that could affect metabolic control due to data constraints [
12,
13]. Furthermore, previous studies have relied primarily on medical records, which has led to a limited understanding of weight status, social participation restrictions, and COVID-19 infection among individuals in the community.
The objective of this study was to investigate the incidence of COVID-19 and its association with weight status and social participation restrictions in adults within the U.S. community utilizing data from the 2021 National Health Interview Survey. Specifically, our aims were to analyze the prevalence of COVID-19 incidence, explore the relationship between COVID-19 incidence, weight status, and social participation restrictions, and identify potential risk factors associated with its occurrence. By investigating these factors within a population-based framework, our study contributes to a better understanding of the broader transmission of COVID-19 and its implications for future public health interventions.
Results
Table
1 shows that 3205 patients were classified as COVID-19, corresponding to an estimated total of 31697404 COVID-19 patients. There were significant differences in the characteristics of the COVID-19 patients based on age, race/ethnicity, level of education, family income index, BMI, and smoking status. Individuals aged 18-59 exhibited a higher percentage of COVID-19 cases compared to those aged 60 or above, with a significant association found between age group and COVID-19 infection. Similarly, significant associations were observed between race/ethnicity, marital status, education level, and family income index with COVID-19 infection, excluding sex. While social participation restrictions did not show significant association with COVID-19, BMI and smoking status did. In particular, overweight (BMI 25<=BMI<30/m
2) and obese (BMI>=30 kg/m
2) individuals had significantly greater COVID-19 incidence than did their corresponding counterparts.
Table 1
COVID-19 cases according to participant characteristics
Age, years | 18-59 | 2336 | 20.7 (22.5) | 25084149 | 105.872 | <.001 |
60 or above | 869 | 14.4 (16.1) | 6613255 |
Mean (SD)/weighted | 52.50 (18.353)/48.12(18.454) |
Sex | Male | 1409 | 18.5 (20.4) | 12498688 | .016 | .901 |
Female | 1796 | 18.5 (21.1) | 17098717 |
Race/ethnicity | White only | 2360 | 18.6 (20.9) | 22766094 | 30.209 | <.001 |
Black/African American only | 378 | 17.8 (19.5) | 3929055 |
American Indian/Alaska native only | 28 | 19.0 (26.9) | 371459 |
Asian only | 117 | 11.7 (12.4) | 1035132 |
other | 75 | 18.4(18.3) | 651917 |
Marital status | Married | 1553 | 19.4 (21.2) | 16283589 | 21.495 | <.001 |
Never married | 862 | 19.0 (21.1) | 9822080 |
Divorced/widowed/separated | 684 | 16.1 (17.9) | 4467898 |
Education | Less than high school | 292 | 22.2 (25.1) | 3191888 | 149.116 | <.001 |
High school | 898 | 23.0 (25.7) | 10309733 |
Associate degree | 949 | 19.9 (21.9) | 8899922 |
College or above | 1048 | 14.5 (15.6) | 9108406 |
Family income index | 0-0.99 | 338 | 20.9 (24.8) | 3584969 | 48.721 | <.001 |
1-1.74 | 452 | 21.9 (25.1) | 4587220 |
1.75-2.99 | 692 | 20.4 (22.6) | 7009102 |
3 or above | 1723 | 16.8 (18.6) | 16516114 |
SPR | Yes | 108 | 17.7 (19.8) | 998728 | .371 | .542 |
No | 3094 | 18.5 (20.8) | 30682518 |
BMI | Under weight (<18.5) | 39 | 14.9 (18.4) | 468188 | 54.277 | <.001 |
Normal weight (18.5<=BMI<25) | 831 | 15.7 (17.9) | 3277390 |
Overweight (25<=BMI<30) | 1094 | 18.8 (21.0) | 10616928 |
Obesity (BMI=>30) | 1176 | 21.1 (23.5) | 11729311 |
Smoking | Yes | 1052 | 17.1 (19.1) | 9303673 | 12.615 | <.001 |
No | 2063 | 19.3 (21.5) | 21442323 |
DM | Yes | 2855 | 18.4 (21.6) | 3100364 | .978 | .323 |
No | 348 | 19.4 (20.7) | 28583758 |
Hypertension | Yes | 1100 | 18.1 (20.5) | 9557507 | 1.252 | .263 |
No | 2102 | 18.8 (20.9) | 22112276 |
Heart attack | Yes | 107 | 17.1 (20.5) | 939011 | .839 | .360 |
No | 3097 | 18.6 (20.8) | 30755959 |
Table
2 displays the correlations between COVID-19 infection incidence and weight status and social participation restrictions. There was a strong correlation between COVID-19 incidence and weight status (
r=0.056,
p=<.001). In addition, weight status was significantly correlated with social participation restrictions (
r=0.012,
p=.043). However, there was no significant correlation between COVID-19 infections and social participation restrictions.
Table 2
Correlations between COVID-19 incidence, weight status and social participation restrictions
COVID-19 infections |
Weight status | .056 (<.001) | | |
Social participation restrictions | -.005 (.542) | .012 (.043) | |
Table
3 shows that the odds analysis revealed significant associations between exposure factors and COVID-19 infection risk. In terms of BMI, individuals classified as overweight exhibited a significantly higher likelihood of COVID-19 infection, with obese individuals showing and even greater risk. In addition, smoking was significantly associated with COVID-19 infection risk. However, health conditions such as DM, hypertension, and heart attack did not exhibit statistically significant associations with COVID-19 infection risk.
Table 3
Factors associated with COVID-19 infection
SPR (ref. no) | Yes | .907 | (.717-1.148) | .418 |
BMI (ref. normal) | Underweight | .894 | (.616-1.296) | .554 |
Overweight | 1.220 | (1.095-1.359) | <.001 |
Obesity | 1.309 | (1.173-1.461) | <.001 |
Smoking (ref. never smoked) | Ever smoked | .832 | (.759-.911) | <.001 |
Health conditions | DM | 1.065 | (.921-1.232) | .359 |
Hypertension | 1.083 | (.978-1.200) | .126 |
Heart attack | .958 | (.756-1.214) | .722 |
Discussion
This study aimed to explore the associations between COVID-19 incidence, weight status, and social participation restrictions in the U.S. The main results showed that weight status was associated with social participation restrictions and COVID-19 infection. Specifically, individuals who were overweight or obese were found to be more susceptible to coronavirus infection, as evidenced by national data in the U.S. As the first study to examine the association of these variables using a nationally representative dataset, the findings of this study have important implications for public health interventions and strategies.
The study revealed a significant association between weight status and social participation restrictions in U.S. adults. Individuals with a higher BMI were more likely to experience limitations in their engagement in social activities. This association can be attributed to the social stigma faced by individuals with larger body sizes in the U.S. [
21], which can lead to social isolation [
22]. Moreover, overweight or obesity can hinder individuals’ participation in various social activities, such as joining local sports teams or engaging in physical activities in public spaces [
23]. The COVID-19 pandemic has further exacerbated these social restrictions through lockdown measures [
24]. In addition, obesity plays a role in creating differences in overall and healthy life expectancy for the U.S. population [
25]. To promote a healthy post-COVID life, it is necessary to implement measures that facilitate social engagement for individuals who are overweight or obese.
In addition, the study emphasized the association between weight and COVID-19 infection, which was supported by public data. Individuals with a higher body weight index were shown to be at an elevated risk of contracting COVID-19. These findings are consistent with emerging evidence suggesting that obesity is a significant risk factor for severe outcomes related to COVID-19 [
5,
7]. During the pandemic, obesity has been shown to be an independent risk factor for increased hospitalization and mortality compared to a normal BMI. Researchers have explained that the pathophysiological understanding of this association involves the inflammatory state associated with obesity [
26]. Another concern is that individuals with obesity often have comorbidities [
27], which further increase their vulnerability to COVID-19 [
28]. Additionally, high BMI and obesity have been identified as risk factors for the development of long-term COVID-19 [
29,
30], which refers to persistent symptoms following the acute phase of the infection. Given these findings, addressing obesity as a public health priority and implementing targeted preventive measures for high-risk populations are crucial.
One notable finding of our study is the lack of significant association between social participation restriction and COVID-19 infection in our regression and correlation models. While this may seem counterintuitive, it underscores the complexity of factors influencing COVID-19 transmission [
31]. Social participation restrictions, although implemented as preventive measures, may not directly correlate with infection rates due to the presence of cofounding variables or other mediating factors that were not fully accounted for in our analysis. Future research should explore additional factors that may mediate or moderate these relationships using additional data sources, which may provide further insights into the relationship between social participation restriction and COVID-19 infection. In addition, while the finding that smokers were less likely to be infected by COVID-19 than never-smokers is noteworthy, it should be interpreted within the broader context of the detrimental effects of smoking on overall health [
32]. Moreover, there are studies that have highlighted the ongoing debate regarding the relationship between smoking and vulnerability to COVID-19 [
33]. Therefore, further research is needed to understand the mechanisms underlying this observed association and its implications for public health policy and practice.
Strengths and limitations
This study contributes to our understanding of weight status, social participation restrictions and COVID-19 infection in several significant ways. First, this study provides a national estimate of the burden of COVID-19 among adults residing in the U.S. in 2021. Second, the study revealed a noteworthy association between weight status and the risk of COVID-19, indicating that effectively managing weight status may reduce the risk of COVID-19. These findings emphasize the importance of developing interventions and policies at the community level, targeting high-risk populations, to address weight and its impact on COVID-19 incidence. Third, the study sheds light on the relationship between weight status and social participation restrictions, emphasizing the need to raise awareness about weight bias and promote education and empathy to reduce social stigmatization toward individuals with larger body sizes. Additionally, this study underscores the significance of recognizing the potential psychological impact of social participation restrictions and providing resources for mental health support.
This study has certain limitations that should be acknowledged. First, the use of self-reported data for the variables introduces the possibility of recall bias and measurement error. Second, the cross-sectional design of the study prevents the establishment of causality or determination of the temporal sequence of events. Conducting longitudinal studies could provide more robust evidence regarding the observed associations. Finally, although the study claims to use nationally representative data, it is important to consider the generalizability of the findings beyond the U.S. population. The relationships between weight status, social participation restrictions, and COVID-19 infection may vary according to culture, socioeconomic status, and healthcare context in other countries. Despite these limitations, the findings of this study, based on nationally representative data, contribute valuable new evidence regarding the association between weight status, social participation restrictions, and COVID-19 incidence. The use of a representative population survey helps to avoid the risk of collider bias [
34]. Unlike previous studies that focused on individuals admitted to hospitals with COVID-19 symptoms, which may introduce sampling bias, this study benefits from the use of national survey data, providing more reliable evidence.
Conclusion
This study offers important insights into the association between COVID-19 incidence, weight status, and social participation restrictions in the U.S. The findings demonstrated that weight status is linked to both social participation restrictions and COVID-19 infection, with overweight and obesity being particularly associated with increased susceptibility to the virus. This finding emphasizes the need to address the impact of weight status on social engagement and COVID-19 infection and advocates for public health interventions targeting weight management and the reduction of social stigmatization. These findings may have significant implications for public health strategies.
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