Introduction
The global health landscape is currently defined by two parallel crises: the burgeoning epidemic of obesity and the persistent threat of infectious diseases. While the link between obesity and chronic metabolic conditions like type 2 diabetes and cardiovascular disease is well-established, its role in modulating the host response to a wide spectrum of infections has remained less clearly defined. A landmark multicohort study published in The Lancet by Nyberg et al. (2026) provides a rigorous, evidence-based quantification of this risk, suggesting that adult obesity is a major, preventable driver of severe infectious disease outcomes globally.
Highlights
- Class III obesity (BMI ≥40.0 kg/m2) is associated with a three-fold increase in the risk of infection-related hospitalizations and mortality compared to individuals with a healthy weight.
- The risk is consistent across diverse pathogen types, including bacterial, viral, fungal, and parasitic infections, and spans both acute and chronic disease states.
- The study estimates that approximately 10.8% of all infection-related deaths worldwide in 2023 were attributable to adult obesity.
- The association remains robust across different measures of adiposity, including Body Mass Index (BMI), waist circumference, and waist-to-height ratio.
Background: The Intersection of Metabolic Health and Immunology
For decades, infectious disease research and metabolic research operated in silos. However, the COVID-19 pandemic served as a stark reminder of how metabolic health dictates the severity of viral infections. Beyond respiratory viruses, clinicians have long observed that patients with obesity often face poorer outcomes in surgical settings or when treating sepsis. Despite these observations, comprehensive data encompassing the full breadth of the infectious disease spectrum—covering nearly 1,000 different conditions—was missing until now. This study addresses that gap by analyzing the incidence, hospitalization, and mortality rates across 925 infectious categories, providing a holistic view of the disease burden.
Study Design: A Dual-Continent Longitudinal Analysis
The researchers utilized a robust multicohort design, pooling data from two major sources: Finnish cohort studies (n=67,766) and the UK Biobank (n=479,498). This provided a total sample size of over half a million participants.
Population and Categorization
Participants were categorized based on their BMI at baseline into five groups: healthy weight (18.5–24.9 kg/m2), overweight (25.0–29.9 kg/m2), and obesity classes I (30.0–34.9 kg/m2), II (35.0–39.9 kg/m2), and III (≥40.0 kg/m2). The mean age of participants was 42.1 years in the Finnish cohorts and 57.0 years in the UK Biobank.
Endpoints and Methodology
Follow-up was conducted through national hospitalization and mortality registries. The primary endpoints were hospital admissions and deaths due to infectious diseases. To ensure the findings were generalizable, the researchers also applied these risk estimates to the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) database to model the Population Attributable Fraction (PAF) of fatal infections worldwide for the years 2018, 2021, and 2023.
Key Findings: Quantifying the Risk of Severe Infection
The study’s results are striking in their consistency and magnitude. During the follow-up period, over 90,000 incident infection cases were recorded across the cohorts.
The Dose-Response Relationship
There was a clear dose-response relationship between BMI and infection severity. Compared with individuals of healthy weight, those in the Class III obesity category (BMI ≥40.0 kg/m2) demonstrated:
- A 2.75 to 3.07 times higher risk of infection-related hospital admissions.
- A 3.06 to 3.54 times higher risk of infection-related death.
Even when looking at the broader category of ‘any obesity’ (Classes I-III), the pooled hazard ratio for severe infection (fatal or non-fatal) was 1.7. This suggests that even moderate obesity significantly elevates the risk profile of a patient when facing an infectious challenge.
Universal Susceptibility
One of the most significant findings was the universality of the risk. The increased susceptibility was not limited to respiratory viruses like influenza or SARS-CoV-2. The association held true for:
- Bacterial infections (e.g., sepsis, pneumonia, urinary tract infections).
- Viral subtypes (including gastrointestinal and systemic viruses).
- Fungal and parasitic infections.
- Both acute presentations and chronic infectious processes.
Global Burden: From Clinical Data to Population Impact
By integrating these hazard ratios with global obesity prevalence data, the study authors estimated the global impact of obesity on infectious disease mortality.
Population Attributable Fractions (PAF)
In 2018 (pre-pandemic), obesity was estimated to contribute to 8.6% of fatal infections globally. This figure spiked to 15.0% in 2021, reflecting the synergistic impact of obesity and the COVID-19 pandemic. By 2023, the estimate settled at 10.8%. These figures indicate that more than one in ten infection-related deaths worldwide could potentially be prevented by addressing adult obesity.
Expert Commentary: Biological Plausibility and Mechanistic Insights
Why does excess adipose tissue lead to such profound infectious vulnerability? Experts suggest several converging mechanisms:
Immunometabolism and Chronic Inflammation
Obesity is characterized by chronic, low-grade systemic inflammation (sometimes called ‘metainflammation’). Adipose tissue acts as an active endocrine organ, secreting pro-inflammatory cytokines such as IL-6 and TNF-alpha. This chronic state of activation can lead to ‘immune exhaustion,’ where T-cells and macrophages are less effective at mounting a rapid, specific response to a new pathogen.
Mechanical and Physiological Factors
In the context of respiratory infections, obesity can impair lung mechanics, reducing functional residual capacity and making the clearance of secretions more difficult. Furthermore, the increased skin-to-skin contact in skin folds can promote bacterial and fungal colonization, leading to more frequent soft tissue infections.
Healthcare Access and Management
Beyond biology, clinical management can be more complex in patients with obesity. Challenges in diagnostic imaging, difficulties with venous access, and the complexities of dosing antibiotics (which are often titrated based on lean body mass rather than total body weight) may contribute to delayed or sub-optimal treatment outcomes.
Conclusion: Integrating Obesity Management into Public Health
This multicohort study provides definitive evidence that obesity is not merely a risk factor for non-communicable diseases, but a primary determinant of infectious disease severity and mortality. The findings suggest that public health strategies aimed at reducing obesity prevalence could have a secondary benefit of significantly reducing the global burden of infectious disease hospitalizations and deaths.
For clinicians, these data underscore the importance of prioritizing vaccinations and early intervention in patients with high BMI. For policy makers, it highlights the need to view obesity prevention as a core component of pandemic preparedness and global health security.
Funding and Registration
This research was supported by the Wellcome Trust, the Medical Research Council, and the Research Council of Finland. The study utilized data from the UK Biobank and Finnish national registries.
References
Nyberg ST, Frank P, Ahmadi-Abhari S, Pentti J, Vahtera J, Ervasti J, Suominen SB, Strandberg TE, Sipilä PN, Meri S, Sattar N, Kivimäki M. Adult obesity and risk of severe infections: a multicohort study with global burden estimates. Lancet. 2026 Feb 9:S0140-6736(25)02474-2. doi: 10.1016/S0140-6736(25)02474-2. Epub ahead of print. PMID: 41679324.
