BACKGROUND: Obesity was recently identified as a major risk factor for worse COVID-19 severity, especially among the young. The reason why its impact seems to be less pronounced in the elderly may be due to the concomitant presence of other comorbidities. However, all reports only focus on BMI, an indirect marker of body fat. AIM: To explore the impact on COVID-19 severity of abdominal fat as a marker of body composition easily collected in patients undergoing a chest CT scan. METHODS: Patients included in this retrospective study were consecutively enrolled among those admitted to an Emergency Department in Rome, Italy, who tested positive for SARS-Cov-2 and underwent a chest CT scan in March 2020. Data were extracted from electronic medical records. RESULTS: 150 patients were included (64.7% male, mean age 64+/-16years). Visceral fat (VAT) was significantly higher in patients requiring intensive care (p=0.032), together with age (p=0.009), inflammation markers CRP and LDH (p<0.0001, p=0.003, respectively), and interstitial pneumonia severity as assessed by a Lung Severity Score (LSS) (p<0.0001). Increasing age, lymphocytes, CRP, LDH, D-Dimer, LSS, total abdominal fat as well as VAT were found to have a significant univariate association with the need of intensive care. A multivariate analysis showed that LSS and VAT were independently associated with the need of intensive care (OR: 1.262; 95%CI: 1.0171-1.488; p=0.005 and OR: 2.474; 95%CI: 1.017-6.019; p=0.046, respectively). CONCLUSIONS: VAT is a marker of worse clinical outcomes in patients with COVID-19. Given the exploratory nature of our study, further investigation is needed to confirm our findings and elucidate the mechanisms underlying such association.