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By Dr. Mark Cucuzzella

As we deliberate about the road to reopening society and search for drugs that could improve outcomes for the coronavirus, we should not miss the opportunity to talk about the conditions that have made Americans especially vulnerable to this pandemic: our poor state of health. Some 60% of the U.S. population has at least one diet-related, chronic diseases, and numerous reports have cited these diseases as associated with increased risk for worsened outcomes from COVID-19. The Centers for Disease Control and Prevention (CDC) recently reported that some 90% of people hospitalized for the virus have one or more disease related to poor diet. Thus, to build resilience to viruses, now and forever, we need to talk about better nutrition

As the Dean of the Friedman School of Nutrition Science and Policy at Tufts University wrote over Twitter,

Limit Sugar Consumption?

Just recently, the World Health Organization (WHO) launched a stay healthy at home campaign, urging adults to limit their sugar consumption to less than six teaspoons a day. No doubt the amount should be even less for children. To give you a frame of reference for what six teaspoons looks like, one small carton of chocolate milk that we freely serve to our children at schools has more than 6 teaspoons of sugar.

Here in the Mountain State of West Virginia where I practice medicine, as well as all the world over, we love to indulge and take comfort in highly processed foods loaded with sugar and refined carbohydrates. Maybe with your gym closed, more stress and time at home, less walking with stay-at-home orders, you or a family member have already succumbed to the ten-pound “COVID cushion.”

The CDC estimates that about 75% of the more than two trillion dollars we spend on health care each year goes to treat chronic illness, much of which can be mitigated by improved diet and lifestyle choices as well as policies that supports these better choices.

The reality is that we are partially responsible for our fragility to an attack such as the coronavirus. Now, we are hoping that our states and our nation can have a strong enough healthcare system to pull us out of this pandemic. But the current crisis reveals how truly vulnerable we are.

COVID and Comorbidity - A Deadly Combination?

Comorbidity means that a patient had at least one other disease in addition to COVID-19. This novel coronavirus emerged in China over five months ago, and we are rapidly discovering how the virus attacks the human body: who it kills and how. U.S. experts attributed the rapid spread and high mortality rates in China to air pollution, higher smoking rates, and advanced age. But a different set of risk factors have emerged as we look retrospectively at the data from China as well as current data in the United States, where obesity is a leading comorbidity.

Just recently, three new studies (here and here and here ) from separate teams in New York City (NYC) point to obesity as a major risk factor for COVID-19 hospitalizations and Intensive Care Unit (ICU) admissions.

In the first study, on more than 3,600 people who tested positive for COVID-19, more than 20% had a BMI of 30-34 (obese, Class 1) and more than 15% had a BMI > 35 (obese, Class 2 or greater). The rate of all obesity in NYC hovers around 28%. West Virginia’s is north of 40%. Importantly though, the rates of ICU admissions were double for those with a BMI over 30 and nearly four times for those with a BMI greater than 35.

The second NYC study looking at over 4,000 COVID-19 patients found that apart from being over 75 years of age, obesity was the most significant risk factor predicting hospitalization and the need for critical care.

The third study looked at records from 5,700 people with COVID-19 who had been admitted to hospitals in NYC. Some 94% of them had at least one comorbidity. The most common were hypertension, obesity and diabetes.

The recent report from the CDC, covering more than a dozen states and thousands of patients reported that hospitalization and complication and death rates were highest amongst those who were ≥65 years of age and those with underlying medical conditions. “Approximately 90% of hospitalized patients identified through COVID-NET had one or more underlying conditions, the most common being obesity, hypertension, chronic lung disease, diabetes mellitus, and cardiovascular disease” stated the report.

A recent meta-analysis of the most current data confirms the greatly increased risk with the usual comorbidities I see daily in my medical practice and our community generally. The study’s conclusion states, “Hypertension, diabetes, COPD, cardiovascular disease, and cerebrovascular disease are major risk factors for patients with COVID-19.”

What Is Happening in Communities of Color?

But what about New Orleans and their Mardi Gras celebrations in late February? Why are so many dying, especially African Americans? Louisiana is a perennial top-five state in obesity with a 37% obesity rate. According to Reuters News and a recent report out of New Orleans, “Some 97% of those killed by COVID-19 in Louisiana had a pre-existing condition, according to the state health department. Diabetes was seen in 40% of the deaths, obesity in 25%, chronic kidney disease in 23% and cardiac problems in 21%. That includes 60% with hypertension, 38% with diabetes and 22% with morbid obesity. Many of the victims suffered more than one of those conditions.”

The CDC’s report revealed that 30% of COVID-19 patients are African American, even though African Americans make up only about 13% of the population of the United States. Regardless of the city or state, be it New York, New Orleans, Chicago, Detroit, or California, the data is consistent.

We have much to study and learn here. African Americans live in historically underserved communities and are less likely to have the supports to lead a healthy lifestyle. Their greater disease rates are rooted in social, economic, physical and even psychological factors such as chronic stress. Native Americans are also extremely vulnerable and may be in the next wave, as COVID-19 finds its way into more remote areas.

However, one factor that whites and blacks, rich and poor all have in common is the need for accurate, evidence-based advice on how lifestyle factors can reverse these diseases. The lesson here is that we should be focusing on everything possible to reduce these rates of diet-related diseases.

Insulin Resistance as a Root Cause

Almost all of those comorbidities, including hypertension, diabetes, coronary artery disease, and obesity are linked to the common root cause of insulin resistance. According to one recent estimate, 88% of Americans having markers of insulin resistance, the root cause of the so-called “metabolic diseases,” that include obesity, Type 2 diabetes and cardiovascular disease. This means only 12% of our population is well. Witnessing how these diseases are increasingly implicated in poor outcomes for coronavirus victims, we need to take insulin resistance far more seriously.

What are the markers of a metabolically healthy individual? See if you pass this test:

Waist Circumference: take 2 times your waist at the belly button- it should be less than your height
Systolic Blood Pressure: < 120 mmHG
Diastolic Blood Pressure: < 80 mmHG
Fasting Glucose: < 100 mg/dL
HbA1c: < 5.7%
Triglycerides: < 150 mg/dL
HDL cholesterol: ≥40 mg/dL in men and ≥ 50 mg/dl in women

Causes of Insulin Resistance

Insulin resistance has been called a “metabolic storm” in the body, where normal functioning breaks down. The principal failure is related to the body’s inability to process sugars in the blood. Whereas a healthy body reacts to sugar consumption by stimulating the pancreas to secrete insulin, which then shunts the sugar off to be stored in the muscles or fat tissues, at some point this insulin mechanism can break down. An overabundance of sugar in the blood stream after many years exhausts the ability of insulin to cope. This is when insulin resistance occurs, resulting in any number of conditions, from Type 2 diabetes to obesity, hypertension and heart disease.

This simple driver of excess sugar in the blood stream is from the food we eat. It is a surprising fact that not only do simple sugars from candy and donuts convert to sugar —glucose — in the bloodstream but so do more “complex” carbohydrates, such as wheat bread, pasta, crackers, and even sweet fruits. These all become glucose as soon as they are digested. Thus, the clear solution is to cut down on the consumption of sugar. Easier said than done, especially in our current stressful environment, but there are now more than one hundred clinical trials collectively showing that a carbohydrate-restricted approach is a safe and effective mode for sustainably reversing a diagnosis of Type 2 diabetes, bringing down blood pressure, improving most cardiovascular risk factors and helping people to lose weight.

Possible Mechanisms for Worse COVID-19 Outcomes with Metabolic Diseases

Based on the preliminary data that has been emerging, the following are some possible ways that obesity and other chronic diseases might contribute to poor COVID-19 outcomes.

The role of ACE- 2 receptor

A virus works by gaining access to the cells of its host and then hijacking a receptor on the cell. In the case of SARS-CoV-2, access is obtained via the ACE-2 receptor, which is why the virus readily enters through the lungs and small intestine—because these tissues have ample amounts of ACE-2 receptors. The vascular system also abounds in these receptors, and they are upregulated in conditions such as hypertension. We are witnessing the lungs, gastro-intestinal system, vascular system, and heart (which is a big vascular organ) as vulnerable to the attack. Studies in this area are still in their infancy, but there is some logic to the idea that metabolically ill people, due to their higher ACE-2 expression, are more vulnerable to the virus.

Endocrine and Metabolic Link

A recent paper, Endocrine and metabolic link to coronavirus infection, discusses the negative impact of the virus on the pancreas, indicating that the coronavirus might exacerbate, or even cause, diabetes by seriously damaging pancreatic islets where insulin is formed. People already with diabetes are at heightened risk, because this condition, combined with SARS-CoV-2 pneumonia, may in fact form a vicious circle, with impaired beta cell function in the pancreas combined with glucose (sugar) dysregulation amplifying the negative effects of the virus.

More recently, we are now witnessing unusual cases of clotting and strokes. This 2006 paper entitled Hyperglycemia Stimulates Coagulation, Whereas Hyperinsulinemia Impairs Fibrinolysis in Healthy Humans suggests that people who are more insulin resistant are less likely to see their clots dissolve and are “especially susceptible to thrombotic events by a concurrent insulin-driven impairment of fibrinolysis and a glucose-driven activation of coagulation.”

The Immune Dysregulation

People with insulin resistance are weakened against the virus due to differences in their immune functioning. A basic concept of immunology is that the immune system exists in two parts: an innate, first responder immune system and a more delayed, adaptive second responder which provides additional immunity. Both of these immune-system arms combine to reflect one’s overall health, and both of these arms are negatively impacted by obesity and metabolic syndrome. In 2017, Anderson described this phenomenon in Impact of Obesity and Metabolic Syndrome on Immunity, and in 2019, Zhou et al. added to the discourse in Longitudinal multi-omics of host–microbe dynamics in prediabetes. The Zhou paper states:

“…during respiratory viral infections, insulin-resistant participants respond differently than insulin-sensitive participants. Third, global co-association analyses among the thousands of profiled molecules reveal specific host–microbe interactions that differ between insulin-resistant and insulin-sensitive individuals.” (Emphases added)

Persistently high blood sugar clearly hinders immune responses, according to this 1972 paper, which states, “Hyperglycemia [high blood sugar] negatively affects white blood cell defense against infection. High glucose impairs these cells in the innate immune response to invading organisms.”

The take-away message here is that for a stronger immune system, avoid sugars and anything that turns to sugar upon digestion.

Role of Cholesterol in COVID

Almost all of my patients who have hypertension, diabetes, and heart disease are told to lower their intakes of saturated fat and cholesterol while taking a cholesterol-lowering medication. Presumably to aid in this cholesterol-lowering, the WHO’s guidance for COVID includes telling people to reduce their saturated-fat intake to zero. However, the focus on cholesterol lowering may have counter-productive effects in fighting the virus.

Studies show the viral antibodies created by our immune systems can partner with cholesterol molecules to become more robust virus killers. Studies on sepsis reflect less mortality with higher HDL-cholesterol and worsened sepsis with low LDL-cholesterol. Data from China are showing how those with the lowest cholesterol are having poorer outcomes, although this phenomenon could well be due to the fact that cholesterol tends to drop when a person enters the acute stage of illness.

Vitamin D, which is involved in cholesterol synthesis pathways, may also have a protective role when stores are sufficient. Several recent studies have shown associations between high vitamin D stores and low-rates of COVID, although these are only associations and do not show causation, i.e., that high vitamin D can prevent COVID. Moreover, the long-term stores developed over many months are likely to the be operative factor here, making short-term supplementation relatively ineffective.

Of course, everything involves tradeoffs, so we are not suggesting that you stop your cholesterol medication, but it is something to consider if your initial indication for taking it was soft. A coronary artery calcium score is a surer way to determine your heart disease risk. Now might be a good time to find out.

For Safer Re-Entry – Eat Real Food

Should my own profession shoulder some of the blame for the obesity pandemic that is exacerbating the COVID pandemic? We have often blamed the victim for having obesity or other diet-related diseases, but these chronic illnesses are affecting up to 80% of the world’s population. My good friend and colleague in sports science, Dr. Phil Maffetone, shares some amazing data in this paper just published this week in entitled The Perfect Storm: COVID-19 Pandemic Meets Overfat Pandemic.

In our current scenario where the course of the virus is difficult to predict, the only true source of control you have is you. The best thing anyone can do is to strengthen his or her resistance to the coronavirus. We are perhaps learning, as Dr. Maffetone states, “that it is easier to prevent viral infections than to treat them. Individuals and governments need not only practice current mitigation strategies such as safe-distancing but must focus on overall health.” Preventing infections requires a healthy immune system —and that means a healthy lifestyle.

Reducing sugar and refined carbohydrates, which fuel insulin resistance, are strongly indicated. Eat for low and stable blood sugar, and if you have diabetes consider a CGM (continuous glucose monitor) to know exactly how the foods you eat are affecting your blood sugar levels. Junk food is the enemy, even if it can be every quarantiner’s best friend. Instead, aim to focus the diet on nutrient-dense whole, real foods, including vegetables, low-sugar fruits, meats, eggs, seafood, and dairy along with the filling, natural fats that accompany them.

Truly healthy people rarely need medication for chronic, lifestyle related conditions. So instead of merely managing your conditions, make it your goal to reverse them, since the risk of COVID-19 will not be like a blizzard (hitting hard and passing over quickly) but rather a long hard winter.

I hope to see a new world where we all take personal responsibility for our own health and those around us, so we can reduce our risk to this pandemic and those perhaps to come. The ongoing pandemics of obesity, diabetes, and metabolic disease remain in the background, exerting their negative effects. It is time to take back our health!

Dr. Mark's: How To Boost Your Host Immune Response

Sleep: shorting yourself of sleep can negatively impact your immune system, so get adequate rest. It’s OK to be a bit less productive.
Stress: no doubt you and others are under stress now. The field of “psychoneuroimmunology” has shown that state of mind matters. So find some time and activities for restoration.
Activity: movement matters. So make sure to get some daily, but not too much. A nice article from my college alma mater, UVA, is here.
Food: To reduce the risk for insulin resistance which leads to metabolic disease, choose nutrient dense foods with healthy fats and proteins as the foundation of your diet. Our clinical guide is here.

About the Author:

Mark Cucuzzella MD, FAAFP is a professor of Family Medicine at West Virginia University School of Medicine and a practitioner at the WVU Center for Diabetes and Metabolic Health https://wvumedicine.org/diabetes-obesity/. Dr. Mark is an author, avid runner, race director for Freedoms Run series, owns a small community running store (which is trying to survive COVID), and advocate for prevention and healthy living.
www.drmarksdesk.com

Note: The Nutrition Coalition does not formally endorse any particular diet; its advocacy efforts are focused on improving the scientific process that produces the Dietary Guidelines and ensuring that this policy is based in rigorous science.