The triumvirate: why hypertension, obesity, and diabetes are risk factors for adverse effects in patients with COVID-19

Acta Diabetol. 2021 Jul;58(7):831-843. doi: 10.1007/s00592-020-01636-z. Epub 2021 Feb 15.


The outbreak of coronavirus disease 2019 (COVID-19) caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a pandemic. The cellular receptor for SARS-CoV-2 entry is the angiotensin-converting enzyme 2, a membrane-bound homolog of angiotensin-converting enzyme. Henceforth, this has brought the attention of the scientific community to study the interaction between COVID-19 and the renin-angiotensin system (RAS), as well as RAS inhibitors. However, these inhibitors are commonly used to treat hypertension, chronic kidney disorder, and diabetes. Obesity is a known risk factor for heart disease, diabetes, and hypertension, whereas diabetes and hypertension may be indirectly related to each other through the effects of obesity. Furthermore, people with hypertension, obesity, diabetes, and other related complications like cardiovascular and kidney diseases have a higher risk of severe COVID-19 infection than the general population and usually exhibit poor prognosis. This severity could be due to systemic inflammation and compromised immune response and RAS associated with these comorbid conditions. Therefore, there is an urgent need to develop evidence-based treatment methods that do not affect the severity of COVID-19 infection and effectively manage these chronic diseases in people with COVID-19.

Keywords: ACE2; Comorbidities; SARS-CoV-2; Viral infection.

Publication types

  • Review

MeSH terms

  • Angiotensin-Converting Enzyme Inhibitors / adverse effects
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use
  • Antihypertensive Agents / pharmacology
  • Antihypertensive Agents / therapeutic use
  • COVID-19 / complications
  • COVID-19 / epidemiology
  • COVID-19 / mortality*
  • Comorbidity
  • Diabetes Complications / drug therapy
  • Diabetes Complications / epidemiology
  • Diabetes Complications / mortality
  • Diabetes Mellitus / drug therapy
  • Diabetes Mellitus / epidemiology*
  • Disease Progression
  • Heart Diseases / complications
  • Heart Diseases / drug therapy
  • Heart Diseases / epidemiology
  • Humans
  • Hypertension / complications
  • Hypertension / drug therapy
  • Hypertension / epidemiology*
  • Obesity / complications
  • Obesity / epidemiology*
  • Pandemics
  • Peptidyl-Dipeptidase A / physiology
  • Renin-Angiotensin System / drug effects
  • Renin-Angiotensin System / physiology
  • Risk Factors
  • SARS-CoV-2 / drug effects
  • SARS-CoV-2 / physiology


  • Angiotensin-Converting Enzyme Inhibitors
  • Antihypertensive Agents
  • ACE protein, human
  • Peptidyl-Dipeptidase A