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Negative impact of COVID-19 and associated preventive measures on cardiometabolic risk

By Dr Soo Lim, MD, PhD
Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea

Soo Lim, MD, PhD
Professor, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam 13620, South Korea
E-mail: limsoo@snu.ac.kr, Tel: +82-31-787- 7035, Fax: +82-31-787-4051


Restrictions introduced in response to the COVID-19 pandemic, such as instructing people not to go outdoors and shutting down exercise facilities, may have contributed to sedentary lifestyle and unhealthy diet and increased risk of cardiometabolic illness.

Our group has investigated the impact of COVID-19 and associated preventive measures on cardiometabolic risk factors in South Korea and found preventive measures against the COVID-19 outbreak have led to a range of other problems.1

We carried out a retrospective observational study using data from 1,485 patients with a mean age of 61.8 ± 11.7 years who visited a tertiary hospital in South Korea at least twice a year for the past 4 years, and compared changes in cardiometabolic factors from the COVID-19 pandemic (2019–2020) with changes in the same data at the same annual time points during the previous seasons from 2016–2019.

During the COVID-19 pandemic, metabolic syndrome worsened in 21% of patients compared with the previous year. Body mass index increased by 0.09 ± 1.16 kg/m2 in the 2019–2020 pandemic period, whereas it decreased by –0.39 ± 3.03 kg/m2 in 2018–2019 and by –0.34 ± 2.18 kg/m2 in 2017–2018 (both p < 0.05). Systolic blood pressure increased, and lipid profiles worsened in the pandemic period compared with the previous years. In our research the Framingham Coronary Heart Disease Risk Score also increased significantly.1

Mobile big data2 has shown that social distancing policies led to a 38.1% decrease in personal movement by the general public in South Korea during the 4th week of the COVID-19 outbreak (February 24–March 1, 2020), compared with the period before a confirmed COVID-19 case was identified (January 9–22, 2020).

Other data has shown that public health interventions such as school closures, instructing people to stay at home and avoid nonessential social activities, had the effect of limiting access to healthy food options.3 Popular delivered meals included pizza, fried chicken, French fries and sugar-containing drinks.4 These foods are reported to be more obesogenic than homemade foods.5 Increased consumption of fast food and sugar-containing drinks is associated with an increased risk of obesity, metabolic syndrome, and type 2 diabetes.6,7

We know that the observations from our research in South Korea are likely to be reflected elsewhere in the world. To prevent spread of COVID-19 many countries have shut down schools, libraries, sports centers and other public facilities. Social distancing requirements of 1m-2m have been imposed, along with requests to stay indoors unless commuting to work was unavoidable.8

According to Community Mobility Reports released by Google (https://www.google.com/covid19/mobility/?hl=en-GB), movement trends decreased in many countries during the pandemic and a recent self-reporting survey also confirmed that people gained weight while spending more time at home.9

While the pandemic may have produced economic disruption and financial hardship which limited access to healthier foods, an increase in TV watching, internet use including social networking and online games instead of outdoor activities, has also been found to have a harmful impact on diet.10

In addition, Covid-19 has had a parallel negative influence on mental health.11 Many people are psychologically distressed by fear of infection or dying which might lead to systemic inflammation.12

Limited access to exercise facilities and disruption of human relationships may increase psychological stress levels. Stress levels have been associated with the release of stress hormones such as cortisol and catecholamines via the hypothalamic–pituitary–adrenal axis.13 Increased levels of catecholamines have an attendant negative effect on the heart and blood vessels.14

Dysregulated metabolic state leads to inappropriate activation of the renin–angiotensin system, increased production of angiotensinogen - up to 30% more circulating angiotensinogen, and to elevated plasma renin activity, which then leads to increased blood pressure and deteriorating glucose metabolism.15

As of March 23, 2021, 123,207,156 Covid-19 cases and 2,715,290 deaths have been confirmed (World Health Organization COVID-19 dashboard [https://covid19.who.int/]). We know it induces mild symptoms in the initial stage but has the potential to result in severe illness, including a systemic inflammatory response syndrome, acute respiratory distress syndrome, multiorgan failure, and death.16

Although the effects of this pandemic may not be seen in the short term, its long-term impacts on cardiometabolic risk cannot be ignored given the accompanying stressful socioeconomic conditions.17

Several groups including ours, have reported that old age, diabetes mellitus, cardiovascular disease, hypertension, metabolic syndrome, and obesity are risk factors for fatal outcomes, and we know elevated release of cytokines in metabolic syndrome status is likely to provoke a “cytokine storm” in people infected with SARS-CoV-2, which may lead to multiorgan failure.18-21

In conclusion, we can see the COVID-19 pandemic will lead to more serious illness and death caused by collateral cardiovascular and metabolic disorders.

The COVID-19 pandemic and its preventive measures are having a negative effect on the cardiometabolic profiles of people with pre-existing metabolic impairment. This means the COVID-19 pandemic will lead to more serious collateral health problems through increasing comorbidity and mortality caused by exacerbation of cardiovascular and metabolic disorders.

We need stronger public health policies and doctors must focus on patients with metabolic impairments to prevent future adverse cardiovascular events. Governments and medical institutions must promote physical activity, healthy eating with home cooked meals, and mental health care during such pandemics. Social media or web-based programs can provide convenient tools to guide patients towards healthy lifestyles. Active counseling to help people with metabolic dysregulation cope with barriers against healthier lifestyles would also be helpful in this critical situation if we are to reduce the deadly impact of COVID-19.22


1.      Sohn M, Koo BK, Lim S, et al. Impact of COVID-19 and Associated Preventive Measures on Cardiometabolic Risk Factors in South Korea: An Observational Study. J Obes Metab Syndr. 2020. DOI: 10.21203/rs.3.rs-127499/v2.

2.     Park IN, Yum HK. Stepwise Strategy of Social Distancing in Korea. J Korean Med Sci. 2020;35(28):e264.

3.     Lim S, Lim H, Despres JP. Collateral Damage of the COVID-19 Pandemic on Nutritional Quality and Physical Activity: Perspective from South Korea. Obesity (Silver Spring). 2020;28(10):1788-1790.

4.     Kim TH, Park Y, Myung J, et al. Food price trends in South Korea through time series analysis. Public Health. 2018;165:67-73.

5.     Fleischhacker SE, Evenson KR, Rodriguez DA, Ammerman AS. A systematic review of fast food access studies. Obes Rev. 2011;12(5):e460-471.

6.     Pereira MA, Kartashov AI, Ebbeling CB, et al.  Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis. Lancet. 2005;365(9453):36-42.

7.     Duffey KJ, Gordon-Larsen P, Jacobs DR, Jr., et al. Differential associations of fast food and restaurant food consumption with 3-y change in body mass index: the Coronary Artery Risk Development in Young Adults Study. Am J Clin Nutr. 2007;85(1):201-208.

8.     Stronger Social Distancing for 15 Days, Starting with the Government! : Ministry of Health and Welfare; 2020.

9.     Zachary Z, Brianna F, Brianna L, et al. Self-quarantine and weight gain related risk factors during the COVID-19 pandemic. Obes Res Clin Pract. 2020;14(3):210-216.

10.  Pearson N, Biddle SJ. Sedentary behavior and dietary intake in children, adolescents, and adults. A systematic review. Am J Prev Med. 2011;41(2):178-188.

11.  Rajkumar RP. COVID-19 and mental health: A review of the existing literature. Asian J Psychiatr. 2020;52:102066.

12.  Mattioli AV, Nasi M, Cocchi C, et al. COVID-19 outbreak: impact of the quarantine-induced stress on cardiovascular disease risk burden. Future Cardiol. 2020.

13.  Stephens MA, Wand G. Stress and the HPA axis: role of glucocorticoids in alcohol dependence. Alcohol Res. 2012;34(4):468-483.

14.  Mattioli AV, Sciomer S, Cocchi C, et al. Quarantine during COVID-19 outbreak: Changes in diet and physical activity increase the risk of cardiovascular disease. Nutr Metab Cardiovasc Dis. 2020;30(9):1409-1417.

15.  Cabandugama PK, Gardner MJ, Sowers JR. The Renin Angiotensin Aldosterone System in Obesity and Hypertension: Roles in the Cardiorenal Metabolic Syndrome. Med Clin North Am. 2017;101(1):129-137.

16.  Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020;323(13):1239-1242.

17.  Mattioli AV, Ballerini Puviani M, Nasi M, et al. COVID-19 pandemic: the effects of quarantine on cardiovascular risk. Eur J Clin Nutr. 2020;74(6):852-855.

18.  Michalakis K, Ilias I. SARS-CoV-2 infection and obesity: Common inflammatory and metabolic aspects. Diabetes Metab Syndr. 2020;14(4):469-471.

19.  Zhou Y, Yang Q, Chi J, et al. Comorbidities and the risk of severe or fatal outcomes associated with coronavirus disease 2019: A systematic review and meta-analysis. Int J Infect Dis. 2020;99:47-56.

20.  Lim S, Bae JH, Kwon HS, et al. COVID-19 and diabetes mellitus: from pathophysiology to clinical management. Nat Rev Endocrinol. 2021;17(1):11-30.

21.  Lim S, Shin SM, Nam GE, et al. Proper Management of People with Obesity during the COVID-19 Pandemic. J Obes Metab Syndr. 2020;29(2):84-98.

22. Patnode CD, Evans CV, Senger CA, et al. Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Cardiovascular Disease Risk Factors: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2017;318(2):175-193.

HQ21OB00125, Approval date: June 2021

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