Ep 144 – Pursuing Health Pearls: What COVID-19 is Teaching Us About Our Health

Ep 144 – Pursuing Health Pearls: What COVID-19 is Teaching Us About Our Health

Last time we talked about the coronavirus it was our very first Pursuing Health Pearls episode just one day before COVID-19 was declared a global pandemic by the WHO.

Over the past 2 months, we’ve experienced dramatic changes to our day-to-day lives from cancellations of large gatherings, to closures of schools and restaurants, and stay-at-home orders in order to “flatten the curve” and decrease the burden of this disease on our health care systems. We’ve seen the stock market crash and hospitals in places such as New York, Washington, and Detroit collapse under the burden of patients with severe disease due to coronavirus infection. There are now millions infected and hundreds of thousands of deaths across the globe.

Lately, a lot of talk about the coronavirus pandemic is focused on re-opening our local economies, the availability of widespread viral PCR and antibody testing, when we’ll have a vaccine, and investigating treatments that might be useful for those with severe illness.

These are all incredibly important topics and things that have to be worked through, but a lot of this talk in the general news media has shifted our attention away from a very important question: “Why are so many of us so vulnerable to this virus, and what can we as individuals do so that we don’t end up in a situation like this again?”

The answer to this question lies in large part on another pandemic that has been mounting over the preceding decades, and that's the pandemic of chronic metabolic disease.

We’re all about getting to the root cause, and from our standpoint it does seem that the prevalence of metabolic disease in our country and world is a big underlying cause for the mess we are currently in. We argue that if we didn’t have such high rates of metabolic disease, it’s likely our populations would not have been so severely affected by this virus, and we may not have been forced to shut down our economies and our lives in order to allow our health care systems time to prepare for the influx of severely ill patients.

Our health care systems were already overrun trying to keep up with the sequelae of chronic disease before COVID-19, and COVID-19 was the final straw, exposing our vulnerabilities and everything that is wrong with our approach to health and health care.

In this edition of Pursuing Health Pearls, we investigate this topic in detail including:

 

  • What we know about who is most susceptible to becoming severely ill from COVID-19
  • The current state of metabolic disease in our population
  • Major drivers of metabolic disease
  • How COVID-19 is thought to cause severe disease in metabolically unhealthy individuals
  • What this pandemic could be telling us on a large scale

Risk Factors for Severe Disease

As COVID-19 has swept the globe, it has become more and more apparent that those who are elderly, obese, or who have chronic metabolic disease are most likely to develop severe symptoms requiring hospitalization or succumb to death from the disease.

Below we’ll highlight some of the data we have now, noting that much of this is published ahead of print and has not been peer reviewed in order to make information publicly available more quickly.

In China, over 72,000 cases of COVID-19 were studied and it was found that older age (≥65 years) and the presence of comorbidities were associated with a more severe course of COVID-19. Among the comorbid conditions, the highest fatality rate was found for cardiovascular disease (10.5%), followed by diabetes (7.3%), chronic respiratory diseases (6.3%), hypertension, (6.0%) and cancer (5.6%).

A smaller study of 191 patients admitted to the hospital for symptoms of COVID-19 in Wuhan, China showed that the most common comorbidities in hospitalized patients with COVID-19 were hypertension (30%), diabetes (19%) and coronary heart disease (8%). Additionally, the odds of dying in the hospital were higher for those with older age.

We see similar findings in the studies that are now coming out of New York. One study of 4,103 patients with COVID-19 in New York City showed that the strongest risk factors for hospitalization were: age >75 (OR 66.8, 95% CI, 44.7-102.6), age 65-74 (OR 10.9, 95% CI, 8.35-14.34), BMI>40 (OR 6.2, 95% CI, 4.2-9.3), and heart failure (OR 4.3 95% CI, 1.9-11.2).

Another case series of 5700 Patients with COVID-19 in New York City revealed that the most common comorbidities among those hospitalized were hypertension (56.6%), obesity (41.7%), and diabetes (33.8%).

As seen in these two large studies from New York, obesity is emerging as an important risk factor for severe disease, and this seems to hold true even in those who are less than 60 years old.

An analysis looking at over 3000 symptomatic patients who tested positive for COVID-19 in New York City found that individuals under age 60 who were obese (BMI >30) were 2-3.6 times more likely to be admitted to the hospital and to require ICU care than those with BMI <30.

This trend between obesity and severe disease was seen in China, too. A study of 383 COVID-19 patients in Shenzhen, China showed those with obesity had a  2.42-fold higher odds of developing severe symptoms. Obese men in particular seemed to have the highest risk of 5.7 fold.

It has also been reported that those with diabetes and metabolic syndrome have up to ten times greater risk of death from COVID-19.

The risk of death does seem to be much higher in those with at least one underlying chronic disease. The CDC reports that overall, 94% of deaths from COVID-19 in the U.S. are in those with at least one underlying chronic disease.

Another recent study which pooled data from France, Italy, Netherlands, Sweden, Georgia, and New York City found that less than 3% of all COVID-19 deaths occured in people less than age 64 years old without underlying conditions. That means the other  97%+ of deaths from COVID-19 occured in people who are over the age of 65 or who have an underlying health condition (cardiovascular disease, hypertension, diabetes, chronic obstructive pulmonary disease and severe asthma, kidney failure, severe liver disease, immunodeficiency, and malignancy).

This is a lot of data, but taken together so far they are telling us that the risk of severe disease is relatively low in those who are young and metabolically healthy.

 

Prevalence of Metabolic Disease and Obesity

Knowing that COVID-19 tends to affect those with chronic disease and obesity more severely, let’s take a look at the prevalence of these conditions among the U.S. population:

Chronic Diseases

  • 6 in 10 adults have chronic diseases
  • 4 in 10 adults have 2+ chronic diseases
  • Chronic and mental health conditions account for 90% of the $3.5 trillion annual health care expenditures in the U.S.

Obesity 

  • 71% of US adults are overweight
  • More than 42% are obese

It’s important to note that a lot of metabolic disease goes underdiagnosed, and diabetes is a prime example of this:

Diabetes

  • >30 Million people in the U.S. have diabetes (about 10%), and 1 in 4 don’t know they have it
  • >84 Million adults in the U.S. (1 in 3) have prediabetes, and 90% of them don’t know they have it

It’s estimated that 20% of normal weight individuals are actually metabolically unhealthy, and also have increased risk of all-cause mortality and cardiovascular events.

A great analysis of NHANES (National Health and Nutrition Examination Survey) data from 2009-2016 showed that only 12.2% of American adults have optimal metabolic health. This is a staggering number, indicating that 88% of our population is metabolically unhealthy! Knowing this, it’s no surprise that we have been hit so hard by the coronavirus pandemic.

 

Drivers of Metabolic Disease

As discussed above, we know that almost 9 in 10 American adults is metabolically unhealthy and therefore at high risk of severe COVID-19. How did we get to this place?

The answer lies in the development of systemic chronic inflammation, which is driven largely by our modern lifestyle factors and environmental exposures.

Below are some of the causes of systemic chronic inflammation that lead to chronic disease:

  • Poor Diet: We know that processed, refined, and sugar-rich foods drive inflammation. In America, 60 percent of our calories come from ultra-processed foods, and it is estimated that our modern diet kills 11 million people globally each year, making it the single biggest cause of death.
  • Physical inactivity: It’s estimated that 50% of American adults are physically inactive, and physical activity is associated with decreased inflammatory markers.
  • Chronic stress: Chronic stress and isolation are major drivers of chronic systemic inflammation, a topic we discussed in detail with Dr. George Slavich in Ep 139 of the podcast.
  • Disturbed sleep: Sleep deprivation and lack of quality sleep contributes to chronic inflammation and immune system disruption.
  • Environmental toxins: Cigarette smoke and excessive alcohol use are some of the most well-known toxins that lead to chronic inflammation, but there are many other toxins we are exposed to in our day-to-day lives that have been shown to alter molecular signaling pathways that lead to inflammation. The Tox21 Program has tested more than 9000 such chemicals including phthalates, bisphenols, and flame retardants, many of which are suspected to play a role in the development of chronic conditions.
  • Chronic infections: While controversial, there are findings to suggest the role of chronic viral infections in the development of systemic inflammation and increased chronic disease risk.

Taken together, these various modern lifestyle behaviors and exposures can drive chronic systemic inflammation, manifesting in a variety of chronic diseases from metabolic syndrome, obesity, diabetes, and cardiovascular disease to cancer, mental health disorders, autoimmune disease, and neurodegenerative disease.

 

How Does COVID-19 Cause Severe Disease in Metabolically Unhealthy People

To our current understanding, there are 3 main factors that play a role in the development of severe disease or even death in those who are metabolically unhealthy:

  • Immune system dysfunction: Immune system dysfunction leads to increased susceptibility to infection as well as decreased vaccine efficacy.
  • Chronic low-grade inflammation: When chronic inflammation is already present, infection with a virus such as coronavirus can cause the immune system to go into overdrive. It is not the coronavirus itself, but the massive inflammatory response including cytokines that are released in a cytokine storm that causes severe disease. This can take the form of Acute Respiratory Distress Syndrome (ARDS) and can lead to multi-organ failure. There is also some evidence that coronavirus can have direct metabolic and endocrine impacts by binding to the ACE2 receptor in blood vessels (increasing blood pressure and vessel permeability) and the pancreas (decreasing insulin release).
  • Chronic organ system disease: Chronic disease of the heart, lung, kidneys or other organs means these organs are already not operating optimally and don’t have as much reserve in the face of an infection like the coronavirus. Those who are obese may also demonstrate impaired respiratory mechanics due to lower lung volumes, decreased respiratory muscle strength, and increased airway resistance, which can lead to decreased lung function and increased stress on the heart.

Image from: https://www.nature.com/articles/s41574-020-0364-6#Fig1

 

Lessons From COVID-19 + What We Can Do

Now that we’ve reviewed how our modern lifestyle has driven a pandemic of metabolic dysfunction in our population making us more vulnerable to COVID-19, let’s take a step back and look at the big picture.

What has the coronavirus pandemic been telling us on a deeper level, and are we going to listen?

We want to put a big disclaimer on what’s coming next, making the point that these are our opinions based on the information we have so far. We also want to make it clear that in no way are we trying to shame or blame anyone who may have a chronic disease or metabolic dysfunction. As we’ve outlined here, the majority of our population is affected by metabolic dysfunction and we believe this is largely driven by systemic issues within our healthcare system, our food system, and the way we live our lives. The COVID-19 pandemic has shed some light on some of these systemic issues and we hope this will drive positive change as we move forward.

 

The Healthcare System

One of the biggest opportunities we see for change comes in our healthcare system. Our healthcare systems were already buckling under the pandemic of chronic disease before the coronavirus came along. Chronic disease was already threatening to bankrupt our country and decreasing the productivity of our workforce and the quality of life of our people.

The coronavirus pandemic has exposed many of the vulnerabilities of our healthcare system. The way the system handles chronic disease is largely by using medications to make “the numbers” look good: blood sugar, blood pressure, cholesterol, etc. Medications might put these numbers in an acceptable range, but when the coronavirus came along it didn’t care - it only cared about the chronic systemic inflammation that was still smoldering underneath and allowed severe COVID-19 to take hold.

We believe that if we want to improve the health and safety of our population and build resilience against the next coronavirus that comes along, we have to abandon our tactic of putting band-aids on problems, and we have to start addressing their root cause.

In the case of coronavirus, a big root cause lies in the lifestyle we have been living that promotes this chronic systemic inflammation and chronic disease. If instead of only 12.2% of our population being metabolically healthy, only 12.2% were metabolically unhealthy, we would be looking at a very different world right now. COVID-19 would probably still be spreading quickly across the globe, but the number of people requiring attention from the healthcare system would be far fewer, and perhaps we wouldn’t have had to take such drastic social distancing measures.

We need to focus our efforts as a culture and as a healthcare system on truly creating health so that we have the reserve to fight against any threat that comes our way, whether it’s another coronavirus or anything else. The only way for us to do this is by addressing the root causes of systemic inflammation which means changing our diets and the way we live our lives.

 

The Food System

This pandemic has also exposed some of the problems with relying on “big food” for our nutrition. Not only does outsourcing our food make us vulnerable to problems in a supply chain, but this food is also less nourishing and more likely to contribute to chronic disease. A better solution would be to focus on local farms and regenerative agriculture.

We also have to work to change our toxic food environment. Foods that are designed to be hyperpalatable and addictive are all around us - there are fast food restaurants on every corner, vending machines and soda in every building, and processed food and sweets easily accessible in every workplace. There is no amount of willpower that would allow someone in this environment to avoid unhealthy foods 100% of the time.

One of the most discouraging things that we’ve observed during this pandemic is the donations of unhealthy food as a way to say “Thank You” to our healthcare workers. Our healthcare workers are doing amazing things in this challenging time, and we feel that saying “Thank You” with foods that are not nourishing, but are actually contributing to the metabolic dysfunction that increases their risk of becoming severely ill from the very disease they are fighting is wildly inappropriate. This highlights the fact that in our culture, sweets and sugar are frequently used as a way to celebrate or reward good behavior. Rarely is there a day that goes by that someone doesn’t bring cake, donuts, cupcakes, or cookies into the office to celebrate something, and this culture further perpetuates our toxic food environment and statistic that almost 9 of 10 of us is metabolically unhealthy.

We have an opportunity to change - whether it’s on a small level by finding other ways to celebrate birthdays or thank your co-workers, growing a garden in your backyard, buying your vegetables from a local farmer, “voting with your fork” by choosing not to purchase foods that are highly processed, or advocating for policy changes - we can all do our part to shift the food system in a direction that supports health.

 

Our Personal Lifestyle Habits

Not only has the pandemic put a spotlight on our healthcare and foods systems, but it’s also showing many of us ways to live a healthier life.

Canceling travel, events, and meetings has forced many of us to slow our pace of life. Suddenly we are confined to our homes and have more downtime, creating an opportunity to spend more quality time with loved ones, take more walks outside, incorporate movement into our daily lives, and even explore cooking at home.

These are all things that we could have been doing all along, but the fast pace of our day-to-day lives often made us feel like we were too busy or didn’t have enough time to spend on these activities that are crucial to our health and well-being.

We think this pandemic is teaching us that illness and disease stems from an imbalance in our relationship with ourselves (what we do and feel) and our relationship with our environment (what we expose ourselves to), and this is our chance to find balance again.

We hope that this difficult time has not been in vain, and that it has helped many of us re-evaluate what’s most important and how we want to continue to live our lives moving forward in a healthier and more sustainable way.

We hope that this is the trigger our healthcare system needed to make some dramatic changes and to shift the focus to creating true health rather than on putting band-aids on disease.

We’re optimistic about the future, and there is so much we can all do. It starts on a local level in each of our homes, continuing with some of the positive habits we’ve developed over the past two months and not allowing them to fall to the wayside as the pace of life picks back up again.

We’ve talked about how young, metabolically healthy people have relatively low risk of severe illness from COVID-19, and we don’t want to minimize the fact that a majority of our population is not in that category. The beautiful thing about this situation is that it is within all of our power to make some simple changes (note they are simple - but not necessarily easy) to our diet and the way we live our lives, to reverse metabolic dysfunction and chronic disease. We’ve seen it happen in a matter of weeks - and there’s no time like the present to get started.

 

Disclaimer: This podcast is for general information only, and does not provide medical advice. We recommend that you seek assistance from your personal physician for any health conditions or concerns.

This post was originally published on May 19, 2020.

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Carla Percy
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Carla Percy

Thank you for all these pearls!! I agree with the connection, it makes so much sense. I really liked where you talked about giving healthcare workers free food but it’s never healthy. We received 5 boxes of donuts the other day. I was thinking it was very nice of whomever purchased those, but if I eat one I know it makes me feel awful so I stayed away.

I really hope there is a push for more wellness care in the future. We deserve that!!

JOHN THOMPSON
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JOHN THOMPSON

Last November my doctor asked me to get the new Shingles vaccine. The only place in town with a supply was Walgreens. When I gave the pharmacist my Medicare prescription drug card, he was shocked that it was the first charge of the year. He said most of his customers had used up their deductible by January or mid February. That goes right along with what you said about how many underlying medical issues people have in this country.

Mike Henderson
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Mike Henderson

Are you still seeing new cases in Ohio? In Southeast Washington, the cases have almost completely gone away.
You have very valid points regarding the connections of chronic disease and obesity/metabolic diseases. As healthcare providers, we have an obligation to model good health behaviors for our patients. One of my wife’s favorite saying is “If you permit it, you promote it”. It is difficult to advise patients to get more exercise and lose weight when the provider is obese and does not exercise.
Thanks again for your words of wisdom and all the work you two are doing.
Mike

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