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Authors

The authors describe a patient whose persistent left superior vena cava was first suspected because of difficulty in placing a right internal jugular venous catheter.

Case In Point: A patient with persistent left superior vena cava

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma.

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma. The violaceous color and configuration of the skin lesions suggests which of the following? 

Clinical Topics

Hard Purple Nodules: Your Dx?

“Obesity truly is a global disease. There are now more people in the world who have excess body weight, and it’s adverse health consequences, than there are people who are underweight,” said obesity expert Donna Ryan, MD, in an interview with 

According to the most recent global estimates from the 

 more than 1.9 billion adults aged ≥18 years were overweight in 2016 and of these adults, >650 million were obese. In 2019, an estimated 38.2 million children worldwide aged <5 years were overweight or obese.

And in the US, the prevalence of obesity has been increasing at a dangerous pace.

Centers for Disease Control and Prevention (CDC)

 the obesity prevalence among adults in the US in 2017-2018 was 42.4%, an increase from 30.5% in 1999-2000 and the first time the national rate has surpassed 40%. Rates of childhood obesity are also rising, with approximately 20% of youth aged 2-19 years now affected, compared to 5.5% in the mid-1970s.

Having obesity puts patients at increased risk for many other serious chronic conditions such as type 2 diabetes and cardiovascular disease, and now the novel coronavirus disease 2019 (COVID-19) has made life even harder for these patients.

As COVID-19 began to spread more rapidly across the US in March 2020, stay-at-home orders were implemented in many states to help mitigate transmission.

Temporary closure to places of employment, restaurants, fitness facilities, and many other public places forced abrupt changes to individuals’ habitual dietary and physical activity patterns.

In turn, social isolation and its negative impact on mental health has been felt by many.

 of 1000 US adults aged ≥18 years, 59% said that their mental health had been affected by COVID-19. More specifically, 35% of participants reported feeling depressed, 37% reported feeling isolated, 48% said they felt anxious, and 49% said they felt stressed out.

Patients with obesity may be at even greater risk for mental health issues during COVID-19.

For example, a global survey published in the journal 

of 7753 adults both with and without obesity during the pandemic lockdown found that while anxiety scores increased for both groups, the magnitude of increase was significantly greater in those with obesity (

 of obesity patients presented at ObesityWeek 2020, researchers from the University of Texas Southwestern Medical Center found that 72.8% of participants reported increased anxiety and 83.6% reported increased depression since COVID-19 stay-at-home orders were initiated.

Another component of emotional distress for patients with overweight and obesity is the specific type of social stigma they experience. The 

 defines weight stigma as the, “discriminatory acts and ideologies targeted towards individuals because of their weight and size.”

Individuals who are obese or overweight are often characterized as undisciplined, unmotivated, or unattractive. They may experience teasing, negative verbal comments, or worse, physical assault. Patients may internalize these harmful stereotypes, resulting in feelings of shame or distress about their body weight or habits.

Unfortunately, weight stigma is common and the associated emotional impact poses yet another psychological threat during the COVID-19 pandemic.

For example, a study published in the October issue of 

identified weight stigma, independent of a person’s body mass index (BMI), as a factor that may worsen eating behaviors and physiological distress for young adults during the pandemic.

Researchers from the University of Connecticut Rudd Center for Food Policy and Obesity and the University of Minnesota analyzed data from 584 young adults (mean age, 24.6 years; mean BMI, 28.2 kg/m

) enrolled in the population-based longitudinal EAT (Eating and Activity over Time) 2010-2018 study, who were invited to complete a follow-up online survey during the pandemic.

Weight stigma previously reported by participants in 2018 was examined as a predictor of binge eating, eating to cope, physical activity, depressive symptoms, and stress during COVID-19. Participants who experienced weight stigma prior to COVID-19 were 

 to engage in binge eating during the pandemic vs those who had not.

Obesity a risk factor for severe COVID-19

“The COVID-19 crisis now has shown us the dark underbelly of American health care,” said obesity and nutrition expert Caroline M. Apovian, MD, director, Center for Nutrition and Weight Management, Boston Medical Center, in an interview with 

“Those who are afflicted with obesity and diabetes are so at risk for the severity of COVID-19, that they are dying.”

In the first meta-analysis of its kind, published August 26, 2020 in 

Patients with obesity face both physical and emotional challenges during the COVID-19 pandemic. How can PCPs help?

Obesity in the Time of COVID: Expert Insights on the Physical, Emotional Toll on Patients

Mahmoud Traina, MD

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