Associations of Global Country Profiles and Modifiable Risk Factors with COVID-19 Cases and Deaths

  1. Samuel Joseph Burden
  2. Josefien Rademaker
  3. Benjamin David Weedon
  4. Luke Whaymand
  5. Helen Dawes
  6. Alexander Jones

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Abstract

Modifiable risk factors affect SARS-CoV-2 infection and mortality raising the possibility that lifestyle modification could play a role. This has not been studied at a global level. We analysed publicly available data from countries reporting COVID-19 cases and deaths. Associations of modifiable risk factors with total cases and excess deaths were determined with and without adjustment for confounders. 4,670,832 cases and 311,384 deaths were reported by 181 countries by 18th May 2020. Wealthier countries had the greatest caseload. Obesity was the primary modifiable risk factor for infection and greater age, male sex, physical inactivity and low salt consumption were associated with excess deaths. Obesity was less influential on mortality than physical inactivity. Globally, obesity confers vulnerability to SARS-CoV-2 infection and physical inactivity likely explains the greater mortality in the obese. High salt consumption may induce reductions in tissue ACE2 expression and subsequently reduce mortality rates.

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  1. Version published to 10.1101/2020.06.17.20133454v2 on medRxiv
  2. ScreenIT

    SciScore for 10.1101/2020.06.17.20133454: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variableA smaller number of countries provided outcome data by sex, which were analysed separately to confirm that findings in the larger analysis were not biased by using combined outcome data for men and women.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Statistics: Statistical analysis was performed using STATA (version 14.2, StataCorp, College Station, Texas).
    STATA
    suggested: (Stata, RRID:SCR_012763)
    StataCorp
    suggested: (Stata, RRID:SCR_012763)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Despite the large study population, the lack of sex-, age- and ethnicity-specific outcome data across all countries was a limitation that we hope will soon be addressed by bodies responsible for collating such data. We addressed this for sex-specific outcomes by repeating our analyses in the subset of countries where sex-specific data were available, with reassuringly similar results. Although some data were not contemporaneous with outcomes, they were measured within the last few years and historical trends in such data (not presented) suggest that they are unlikely to have changed significantly. In this study of global COVID-19 cases and deaths, obesity in men and women was the primary modifiable risk factor for SARS-CoV-2 infection. Greater age, male sex, PI and a low salt intake were associated with excess COVID-19 death, after adjustment for confounders. To the best of our knowledge, we are the first to show that obesity is not a risk factor for excess death when PI is adjusted for. We also showed that HBP is not associated with excess deaths once age and other confounders are adjusted for. Finally, a high salt intake was associated with lower numbers of cases and excess deaths and we hypothesize that resultant lower levels of ACE2 in the lungs and the myocardium, amongst other tissues, could mediate these findings.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

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  3. Version published to 10.1101/2020.06.17.20133454v1 on medRxiv