The Association Between Obesity and COVID-19 Severity in Children Differed Between SARS-CoV-2 Variants: A Multicountry Hospital-Based Observational Study

Abstract

Background: Obesity was a risk factor for severe COVID-19 in children during early outbreaks of ancestral SARS-CoV-2 and the Delta variant. However, the relationship between obesity and COVID-19 severity during the Omicron wave remains unclear. Methods: This multicenter, observational study included polymerase chain r eaction-confirmed SARS-CoV-2-infected children and adolescents from Australia, Brazil, Italy, Portugal, Switzerland, Thailand, the United Kingdom and the United States hospitalized between January 1, 2020, and March 31, 2022. Data were collected across 3 time periods representing dominant SARS-CoV-2 variants: the ancestral strain (T1), pre-Omicron variants (Alpha and Delta; T2) and Omicron (T3). The primary outcome was the need for supplemental oxygen therapy and/or ventilatory support (respiratory support). Results: This study included 6176 hospitalized children and adolescents of 2 to <18 years of age. The median age was 11.0 (interquartile range, 6.0–14.0) years, and 2989 (48.4%) were female. Obesity status was available for 5460 (88.4%), of whom 213 (3.9%) met the criteria for having obesity. Obesity was positively associated with the need for respiratory support during T1 [risk ratio (RR), 3.45 (95% CI: 2.02–5.88)] and T2 [RR, 3.24 (95% CI: 1.57–6.67], but this association was lost during T3 [RR, 3.08 (95% CI: 0.85–11.15)]. These findings were similar for unvaccinated children. Conclusions: Obesity was associated with more severe COVID-19 during the ancestral and pre-Omicron waves but not during the Omicron wave. Importantly, the same phenomenon was observed in unvaccinated children, suggesting that differences in vaccination did not account for the observed changes in the need for respiratory support over time.