PERSPECTIVE
Poor metabolic health is a major issue for increased
COVID-19 mortality in BAME patient groups
Aseem Malhotra 1, Ravi Kamepalli 2, JS Bamrah 3
1 Consultant Cardiologist, Visiting Professor of Evidence Based Medicine, Bahiana School of Medicine and Public
Health, Salvador, Brazil
2 Consultant in Infectious Diseases and Obesity, Regional Infectious Diseases Infusion Centre, Lima, Ohio, United States
3 Consultant Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
Keywords
HbA1C, BAME, Metabolic disease, COVID-19
Editorial Note
Type 2 diabetes mellitus and hypertension are the most common comorbidities in patients with coronavirus infections.
Emerging evidence demonstrates an important direct metabolic and endocrine mechanistic link to the viral disease
process. Metabolic syndrome (METS) is a common denominator to these comorbidities and includes insulin resistance,
dyslipidaemia, central obesity and hypertension, which are risk factors for the development of type 2 diabetes and
cardiovascular diseases. In 2017, it was estimated that METS affected 20% of North American population, 25% of
European population and approximately 15% of Chinese population. In this scenario, the relationship between METS
and its comorbidities that aggravate the COVID-19 prognosis cannot be ignored. Also, its presence in different ethnicities
and continents places METS as an important risk factor for COVID-19. The authors offer their scientific and
epidemiological perspective on this emerging association and urge an international awareness of its devastating
consequences among certain populations. This article welcomes debate among scientists, policy makers and wider
community leaders. The authors urge clinicians to encourage thorough metabolic control for all patients at risk of COVID-
19. (a,b) The Physician welcomes contributions from interested scientists, policy makers and patient representative
organisations to continue this discourse.
Article Information
Submitted
5 Jul 2020
Pre-print
8 Jul 2020
Cite as: Malhotra, A., Kamepalli, R., Bamrah, J.S. (2020) Poor metabolic health is a major issue for increased COVID-19
mortality in BAME groups. The Physician Vol 6 issue 2 epub 8.07.2020 DOI: 10.38192/1.6.2.4
Introduction
According to Public Health England those from Black, Asian
increased mortality risk. However, correcting for “co-
and Minority Ethnic (BAME) backgrounds are at increased
morbidities” the risk is greatly reduced if not eliminated.
risk of poor outcomes from COVID-19. After accounting for
(1)
effect of sex, age, deprivation and region Bangladeshi’s are
It is a known fact that those from South Asian backgrounds
twice risk of death compared to white British. Other ethnic
(2 billion of the world’s population) have a type 2 diabetes
groups including Chinese, Indian, Pakistani, other Asian,
prevalence at least twice as high as Caucasians and
Caribbean and other black ethnicity had a
10-50% develop the condition five to ten years earlier at lower
1
2020
levels of adiposity.(2) Two thirds of type 2 diabetes deaths
are due to thrombotic complications and amongst Asian
Unfortunately, the current NHS risk assessment tool
Indians in India
52% of cardiovascular death occurs
doesn’t directly measure metabolic health which is a more
prematurely, in those under the age of 70. (3) If these
sensitive method to identify and subsequently manage
premature fatalities trends from heart attack and stroke
BAME individuals at high risk.
continue it’s estimated that it will cost the Indian economy
$2 trillion by 2030.
Identifying and managing the causes of the causes
Eighty percent of chronic metabolic disease is rooted in
Why the greater risk amongst BAME?
lifestyle and environment. Medical literature data is not
Obesity and conditions of the metabolic syndrome are
well publicised on the dietary and lifestyle behaviours of
associated with impaired innate and adaptive immunity.
those from BAME backgrounds but what is available paints
Underlying chronic inflammation also linked to excess
a concerning picture. In essence an inherent susceptibility
body fat appears to potentiate risk of the cytokine storm
to METS is then exacerbated by poor lifestyle behaviours.
of the Acute Respiratory Distress syndrome. (4)
Poor Diet
Optimal metabolic health is having all five, and the
metabolic syndrome (METS) is defined as failing to achieve
A 2007 study in JAMA revealed low intake of whole fruit
at least three of the following:
and vegetables, as a risk factor for early myocardial
infarction, was very common amongst South Asians, living
• Blood Pressure
(systolic
<120 and diastolic
in the US even amongst vegetarians. (8) Furthermore, the
<80mmHg)
average Indian is consuming more than double the ideal
• HbA1c < 5.7%
maximum limit of sugar recommended as daily intake from
the World Health Organisation. (9) A diet high in refined
• Waist Circumference <102cm for a man <88cm
carbohydrates and ultra-processed foods is likely to be a
for a woman (for south sians it’s <90cm for a
man and <85cm for a woman)
causative factor in driving metabolic syndrome in South
• Blood Triglycerides <1.7mmol/l (< 150mg/dL)
Asians.
• HDL-C
>1mmol/l
(>40/50mg/dL for
Inadequate physical activity
men/women)
A cross sectional study revealed that South Asians may
Disturbingly only
1 in
8 American adults are now
require 233 minutes a week of moderate activity a week
considered to have optimal metabolic health (5) Although
to have the same cardiometabolic benefits of white
there are age disparities, the young are also adversely
Europeans carrying out 150 minutes. South Asians, in part
affected with 1 in 4 aged between 20 and 40 having
due to lower muscle mass, may have a genetic
optimum parameters. On a biological level chronic
predisposition to lower cardiorespiratory fitness than
hyperinsulinemia and/or insulin resistance is strongly
Caucasians. (10) Amongst all BAME groups in the UK
associated in the pathogenesis and likely causal. (6)
average levels of physical activity are also considerably
lower that white British. The latest data from sport
But just as racism is endemic in the UK National Health
England reveals 62% of adults in England meet the Chief
Service (NHS) racial bias exists in the identification and
Medical Officer’s physical activity guidelines compared to
management of patients from BAME backgrounds at high
just 56% of Black people and 55.1% of Asians.
risk. Using Body Mass Index (BMI) as a proxy for “healthy
weight” may provide the illusion of protection and will
Low Vitamin D status
miss a substantial proportion of those from black and
south Asian ethnic minority groups with METS risk. This is
Vitamin D plays an essential role in innate and adaptive
due to an inherent propensity for METS even at lower
immunity. Severe Vitamin D deficiency which has been
levels of intra-abdominal adiposity. For example, data
strongly correlated with adverse outcomes from COVID-19
from the United States reveals 43.6% of normal BMI south
also has a high prevalence amongst BAME groups in the
Asians are metabolically unhealthy, compared to 38.5% in
UK. The majority of those from South Asian of Black
Hispanics, 32.2% in Chinese Americans, 31.1% in African
backgrounds are either deficient or severely deficient. (11)
Americans, and 21% in whites. Normal BMI metabolically
unhealthy have a threefold increased all-cause mortality
It’s imperative that those from BAME backgrounds know
and or cardiovascular event risk compared to
their Vitamin D status but it’s not currently routinely
metabolically healthy normal weight over a ten-year
measured in primary care. In those who are deficient
period. (7)
2
2020
measures should be taken to correct it. More sun exposure
associated comorbidities and proposed therapies.
is required to generate adequate levels compared to those
Diabetes & Metabolic Syndrome: Clinical Research &
of lighter skin colour. If it is not possible to obtain adequate
Reviews,
2020
14(5),
809-814,
levels through increased sun exposure or through diet
then supplementation should be offered. The most
important food sources of Vitamin D are fatty fish, cod liver
1.
Harrison, E., Docherty, A., Semple, C.
(2020)
oil, eggs and mushrooms.
Investigating associations between ethnicity and
outcome from COVID-19 UK Gov CO-CIN ePub
Health inequalities require a broader approach
25/04/2020
(accessed
7.7.2020)
Numerous dietary intervention studies reveal rapid
benefits in improving metabolic risk factors. (12) It is
plausible that this would also simultaneously reduce risk
of severity of COVID-19 complications. For example, better
2.
Unnikrishnan, R., Anjana, R.M., Mohan, V. (2014)
glucose control on hospital admission in type 2 diabetes
Diabetes in South Asians: Is the Phenotype
patients has revealed a ten-fold difference in COVID-19
Different?
Diabetes 63 (1) 53-
mortality risk between those with the worst control. (13)
55; DOI: 10.2337/db13-1592
A recent small randomised trial revealed reversal of METS
3.
Chauhan, S., Tamber Aeri, B. (2013) Prevalence of
in over half of participants within 28 days of a dietary
cardiovascular disease in India and its economic
changes in obese adults. This was independent of weight
impact- A review. Int J Scien Res Publ,
3(10)
loss. (14) More research and publicity on diet and lifestyle
interventions in metabolically unhealthy BAME groups
including those with a normal BMI who are at highest risk
4.
Andersen CJ, Murphy KE, Fernandez ML. (2016)
is also urgently required.
Impact of Obesity and Metabolic Syndrome on
Immunity. Adv
Nutr.
7(1):66-75.
doi:10.3945/an.115.010207
We also cannot ignore the bigger picture issue. All the
5.
Arau´ jo, J., Cai, J., Stevens, J. (2019) Prevalence of
biological risk factors (as well as increased psychological
Optimal Metabolic Health in American Adults:
stress) in ethnic minority groups will be fueled by socio-
National Health and Nutrition Examination Survey
economic factors. The disproportionate impact of COVID-
2009-2016. Metabolic syndrome and related
19 on BAME communities has also highlighted racial and
disorders. 17(1) Mary Ann Liebert, Inc. Pp. 46-52
social injustices. The power of modern medicine is
DOI: 10.1089/met.2018.0105
dwarfed by the power of prevention and the wider
6.
Kelly, C.T., Mansoor, J., Dohm, G.L., Chapman III,
determinants of health. In our view the medical profession
W.H.H., Pender IV, J.R., Pories, W.J.
(2014)
and policy makers have an ethical and moral duty to be
Hyperinsulinemic syndrome: The metabolic
advocates for policy change to reduce health inequalities.
syndrome is broader than you think. Surgery 156 (2);
(15) This would have a far greater impact on population
405-411
health than downstream individually tailored behaviour
change. As pioneering German Physician Rudolf Virchow
7.
Stefan, N., Schick, F., UlrichHaring, H. (2017) Causes,
said “for medicine to fulfil her greatest task she must also
Characteristics, and Consequences of Metabolically
enter the political and social life”. But the evidence is clear,
Unhealthy Normal Weight in Humans. Cell
time for action on metabolic health is long overdue.
Metabolism
26
(2)
292-300
Otherwise there will be even more misery and devastation
when the next pandemic comes round.
8.
Joshi P, Islam S, Pais P, et al. Risk Factors for Early
Myocardial Infarction in South Asians Compared
With
Individuals
in
Other
Authors declare no conflict of interest
Countries. JAMA. 2007;297(3):286-294.
There is no funding declared with this article
doi:10.1001/jama.297.3.286
9.
Dasgupta R, Pillai R, Kumar R, Arora NK. Sugar, salt,
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