The impact of COVID‐19 on obesity services across Europe: A physician survey

Summary Obesity is a risk factor for severe complications from coronavirus disease 2019 (COVID‐19). During the COVID‐19 pandemic in Spring 2020, many clinics and obesity centers across Europe were required to close. This study aimed to determine the impact of COVID‐19 on the provision of obesity services across 10 European countries via a survey of physicians (n = 102) specializing in treating persons with obesity (PwO). In total, 62–95 out of 102 physicians reported that COVID‐19 affected obesity‐related services, with cancellations/suspensions ranging from 50% to 100% across the 10 countries. Approximately 75% of cancellations/suspensions were provider‐ rather than patient‐initiated. A median increase of 20%–25% in waiting times was reported for most services across the countries. When services resume, 87 out of 100 physicians consider factors influencing down‐stream patient outcomes as the most relevant factors for prioritizing interventional treatment. Responses showed that 65 out of 102 and 36 out of 102 physicians believed it (highly) likely that a change in treatment guidance will occur to prioritize earlier interventional treatment for the management of PwO, by either using bariatric surgery or pharmacotherapy, respectively. Results from this study provide important learnings, such as opportunities for, and discrepancies in, the provision of alternative care in light of services cancellations or delays, which may be important for the future management of obesity, especially during future waves of COVID‐19 or other infectious pandemics.


Summary
Obesity is a risk factor for severe complications from coronavirus disease 2019 . During the COVID-19 pandemic in Spring 2020, many clinics and obesity centers across Europe were required to close. This study aimed to determine the impact of COVID-19 on the provision of obesity services across 10 European countries via a survey of physicians (n = 102) specializing in treating persons with obesity (PwO). In total, 62-95 out of 102 physicians reported that COVID-19 affected obesity-related services, with cancellations/suspensions ranging from 50% to 100% across the 10 countries. Approximately 75% of cancellations/suspensions were provider-rather than patient-initiated. A median increase of 20%-25% in waiting times was reported for most services across the countries. When services resume, 87 out of 100 physicians consider factors influencing down-stream patient outcomes as the most relevant factors for prioritizing interventional treatment. Responses showed that 65 out of 102 and 36 out of 102 physicians believed it (highly) likely that a change in treatment guidance will occur to prioritize earlier interventional treatment for the management of PwO, by either using bariatric surgery or pharmacotherapy, respectively. Results from this study provide important learnings, such as opportunities for, and discrepancies in, the provision of alternative care in light of services cancellations or delays, which may be important for the future management of obesity, especially during future waves of COVID-19 or other infectious pandemics. Tracker provide indications that "stay at home" requirements were implemented in March 2020 and ranged from localized recommendations (e.g., Denmark, Finland, Sweden and the Netherlands) to localized and national lockdowns (Belgium, France, Ireland, Portugal, Spain and the UK) throughout the first wave of the COVID-19 pandemic. 1 The European Society of Residents in Urology reports major elective surgeries being cancelled in France, Germany, Italy, Spain and the UK as a result of the COVID-19 pandemic in Spring 2020, 2 a scenario that was likely mirrored across Europe.
The cost of the disruption to medical services due to the pandemic has directly affected patients awaiting surgery. According to a study by the CovidSurg Collaborative, approximately 28.4 million elective surgeries were projected to be cancelled worldwide as a result of a 12-week period of peak disruption during the first wave of the COVID-19 pandemic. 3 In the UK, the decision to postpone all nonurgent elective operations for at least 3 months during the first wave of the pandemic (Spring 2020) was estimated to result in 516 000 surgeries being cancelled. 4 This backlog has since increased with subsequent lockdowns. 5 COVID-19 is associated with several comorbidities including obesity, arterial hypertension, chronic lung disease, diabetes and cancer, [6][7][8] with obesity being the most common comorbidity for patients infected with COVID-19. 9,10 Additionally, evidence suggests that persons with obesity (PwO) who contract COVID-19 have a higher risk of developing a severe illness due to the virus. 7,8,[11][12][13][14][15] Several explanations for why PwO are more susceptible to severe disease with COVID-19 have been proposed, including impaired lung function, 16 endothelial dysfunction, 14 and inflammation. [17][18][19] Other respiratory diseases, including influenza 20,21 and the H1N1 2009 strain of influenza, 19,22,23 adversely affect PwO indicating that this population may be at heightened risk of developing severe illness due to COVID-19.
Although younger age is considered to lower the risk for COVID-19 disease severity, a growing body of evidence indicates that obesity in people aged <60 years is a risk factor associated with increased COVID-19 disease severity and a risk factor for hospital admission and critical care. Patients with COVID-19 and a BMI between 30-34 kg/m 2 were 2.0 and 1.8 times more likely to be admitted to acute and critical care, respectively, compared with individuals with a BMI <30 kg/m 2 . 11 Additionally, those with a BMI ≥25 kg/m 2 had significantly higher odds of developing severe COVID-19 disease requiring supplemental oxygen and intensive care admission. 24 An inverse correlation between age and BMI has also been suggested, in which younger people admitted to hospital with COVID-19 were more likely to have obesity, indicating that in populations with a high prevalence of obesity, COVID-19 will affect younger populations more than initially reported. 25 Alongside obesity being linked to severe incidence of COVID-19, it has also been identified as an independent risk factor for high mortality in a large (>20 000 hospital inpatients) prospective observational cohort study in the UK between 6 February and 19 April 2020. 26 Given the link between obesity and severe COVID-19 disease and high mortality, it is imperative that PwO are adequately managed and treated. Any impact on the ability to adequately manage PwO may put patients at risk of developing and exacerbating comorbidities of obesity, and more severe infections of COVID-19.
Current European guidelines for the treatment of obesity recommend an integrated treatment of obesity that may include diet, physical activity, pharmacological treatment, behavioural therapy and if indicated, bariatric or metabolic surgery, with multidisciplinary provision of care. 27,28 A recent publication by Rubino et al., provides comprehensive recommendations for prioritizing and managing surgical candidates and post-operative patients during and after the peak of COVID-19 waves, including pre-operative screening, non-surgical interventions and triaging of patients for priority surgery. 29 When surgeries can resume, it has been proposed to stratify PwO based on a benefit/risk assessment with priority for those PwO whose need for surgery is high provided that the risk of morbidity due to the surgery is very low. 30 Increased vigilance, priority on COVID-19 detection and testing, and aggressive therapy are recommendations for PwO and COVID-19 infections. 23 Given the highly relevant link between COVID-19 and obesity for healthcare services and public health bodies, it is essential to understand how services for PwO have been impacted by the pandemic.
Here, we report the results of a quantitative survey with physicians involved in the treatment of PwO to understand the impact of COVID-19 on obesity services across Europe in Spring 2020.  Table S1).

| Survey results
In  (Table S2). Across all countries, the COVID-19 pandemic impacted all obesity services considered, with routine medical consultations by specialists and non-specialists, and bariatric procedures reported as affected by the greatest number of physicians per country, whilst other health-related consultations by a multi-disciplinary team were reported to be affected by COVID-19 by the least number of physicians per country.
Consequently, these procedures may be at risk of cancellation dur-