What is the clinical evidence from this study?

Study design: Cohort. Population: SARS-CoV-2 infection (n=8412). Intervention: Higher pericardial adipose tissue (PAT) on pre-pandemic CT vs. Lower pericardial adipose tissue. Primary outcome: Time to hospitalization or death from SARS-CoV-2 infection (HR 1.62, 95% CI 1.25-2.09).

What does this research mean for the field?

Greater CT-measured pericardial and abdominal visceral adipose tissue are associated with increased hazards of hospitalization or death from SARS-CoV-2, independent of traditional body mass index and cardiometabolic comorbidities. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

This study aims to evaluate the relationship between different adipose tissue types and the risk of SARS-CoV-2-related hospitalization or death.

May 26, 2026Open Access

CT-adipose measures identify severe SARS-CoV-2 risk beyond traditional obesity metrics: a C4R cohort study

Key Result

Greater CT-measured pericardial adipose tissue was associated with a 62% increased hazard of hospitalization or death from SARS-CoV-2 per doubling of volume, independent of BMI and comorbidities.

Key Points

This study aims to evaluate the relationship between different adipose tissue types and the risk of SARS-CoV-2-related hospitalization or death.
Analysis based on data from the Collaborative Cohort of Cohorts for COVID-19 Research (C4R) involving participants from multiple US cohorts.
Primary exposure measured was adipose depot size from CT scans taken before the pandemic.
Primary outcome assessed was time to hospitalization or death from SARS-CoV-2 from March 1, 2020.
Of 8412 participants, 184 experienced hospitalization or death over 547 days.
Higher pericardial adipose tissue (PAT) increased the hazard ratio (HR 1.62, 95% CI 1.25–2.09).
Higher abdominal visceral adipose tissue (VAT) also increased the risk (HR 1.41, 95% CI 1.20–1.67) independent of BMI and comorbidities.

Study Design

Type

Cohort (n=8,412)

Multicenter

Yes

Structured PICO

Does greater CT-measured adipose tissue increase the risk of hospitalization or death from SARS-CoV-2 in adults?

Population

8,412 participants from 4 US-based longitudinal cohort studies (MESA, JHS, CARDIA, FHS) who were alive on March 1, 2020, and had at least one pre-pandemic CT adipose measure.

Intervention

Adipose depot size (pericardial adipose tissue [PAT], abdominal visceral adipose tissue [VAT], subcutaneous adipose tissue [SAT], or hepatic adipose deposition) measured on research CT scans performed between 2000 and 2011.

Outcome

Time from March 1, 2020 to hospitalization or death from SARS-CoV-2 infection (severe events), ascertained by self-report or active surveillance and confirmed by protocolized record review.hard clinical

CT-measured pericardial and abdominal visceral adiposity are associated with increased risk of severe SARS-CoV-2 infection, independent of BMI and clinical cardiometabolic comorbidities.

Main Result

Effect estimate: HR 1.62 (95% CI 1.25-2.09)

Limitations

CT measures were obtained 10-20 years prior to the pandemic, and depots may increase over time.
Protocols for measurement of abdominal adipose tissue differed across cohorts.
Ascertainment of mild infection was primarily dependent on testing and self-report.
Approximately 6% of eligible cohort participants did not enroll in C4R, potentially introducing selection bias.

Abstract

Background Higher body mass index (BMI) increases risk of respiratory failure and death from SARS-CoV-2 infection. BMI is imprecise and fails to account for adipose tissue distribution. We sought to determine whether pericardial adipose tissue (PAT), abdominal visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), or hepatic adipose deposition on pre-pandemic computed tomography (CT) scans associate with increased risk of hospitalization or death from SARS-CoV-2. Methods The Collaborative Cohort of Cohorts for COVID-19 Research (C4R) ascertained SARS-CoV-2 outcomes among participants from 14 US-based cohort studies. This analysis includes participants enrolled in the Jackson Heart, CARDIA, MESA, and Framingham Heart studies. C4R attempted to enroll all cohort participants who were alive on March 1, 2020 and had not withdrawn consent for cohort participation. Our primary exposure was adipose depot size measured on research CT scans performed between 2000 and 2011. Our primary outcome was time from March 1, 2020 to hospitalization or death from SARS-CoV-2 infection ascertained by self-report or active surveillance and confirmed when available, by protocolized record review. Results There were 8412 participants with at least one CT adipose measure, among whom 184 events occurred over a median (interquartile range) of 547 (338–609) days. In adjusted models, both higher PAT (per doubling in PAT, HR 1.62, 95% CI 1.25–2.09) and higher VAT (per 1-standard deviation, HR.41, 95% CI 1.20–1.67) associated with greater hazards of hospitalization or death from SARS-CoV-2. Associations remained after adjustment for BMI, diabetes, cardiovascular disease, hypertension, and waist circumference. SAT was associated with hospitalization or death but not after adjustment for BMI and obesity complications. Hepatic adipose deposition was not associated with hospitalization or death. Conclusion Greater CT-measured pericardial and abdominal visceral adipose tissue were associated with increased hazards of hospitalization or death from SARS-CoV-2 independent of BMI and clinical cardiometabolic comorbidities. Further research should investigate use of CT adipose measures to quantify risk of severe disease from viral infections and to investigate mechanisms linking adiposity to lung injury.

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