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COVID-19, Lifestyle interventions more effective than drugs.

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So far drug intervention trials for treating COVID-19 have been disappointing. No studies have shown benefit for hydroxychloroquine, with or without azithromycin. This topic has been covered in previous posts. Remdesivir has been FDA approved based upon one study that showed reduction in duration of symptoms. The mortality rate with Remdesivir, however, did not demonstrate a statistically significant difference when compared to “usual care”. https://www.niaid.nih.gov/news-events/nih-clinical-trial-shows-remdesivir-accelerates-recovery-advanced-covid-19

Another study published in Lancet failed to show any clinical benefit from Remdesivir.

“No statistically significant benefits were observed for remdesivir treatment beyond those of standard of care treatment. Our trial did not attain the predetermined sample size because the outbreak of COVID-19 was brought under control in China. Future studies of remdesivir, including earlier treatment in patients with COVID-19 and higher-dose regimens or in combination with other antivirals or SARS-CoV-2 neutralising antibodies in those with severe COVID-19 are needed to better understand its potential effectiveness.”

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31022-9/fulltext

But we do know that certain underlying conditions such as obesity, diabetes, pre-diabetes (insulin resistance) and hypertension significantly increase risk of DEATH AND COMPLICATIONS with COVID-19. Since there are lifestyle interventions that can quickly and effectively mitigate these problems (diet, exercise, sleep, stress reduction….) now would seem like a good time to take our epidemics of obesity and diabetes in hand with aggressive lifestyle interventions to decrease the mortality rate of COVID-19 infection. Such measures do not require expensive drugs or expensive drug trials, they simply require knowledge, guidelines and the will to implement change in our daily habits. Yet there has been little discussion about this in the media or on the part of public health officials.

Lets look at obesity in the US.

From 1999–2000 through 2017–2018, the age-adjusted prevalence of obesity increased from

30.5% to 42.4%, and the prevalence of severe obesity increased from 4.7% to 9.2%.

Click to access db360-h.pdf

The most effective tool for addressing obesity and diabetes is a very low carbohydrate diet.

Effects of the Low Carbohydrate, High Fat Diet on Glycemic Control and Body Weight in Patients With Type 2 Diabetes: Experience From a Community-Based Cohort

https://pubmed.ncbi.nlm.nih.gov/32193200/

This study was a done in a community-based program, not an academic practice setting. That is significant since it demonstrates feasibility outside of academic centers with standard community resources. The results of this study confirmed the results of many previous studies done in academic settings including better blood sugar control, reduction or elimination of diabetic medications, and significant weight loss.

“All patients following the LCHF diet who initially took
insulin had either a reduction or discontinuation of
this therapy by their healthcare provider when clinically
indicated, compared with less than a quarter of
those receiving usual care.“

In another study done in Italy, significant weight reduction (7 kg), waistline reduction (7 cm.), fat mass reduction (3.8%) and systolic blood pressure reduction (10.5 mmHg) were achieved in 3 months with a Very Low Carbohydrate diet.

Middle and Long-Term Impact of a Very Low-Carbohydrate Ketogenic Diet on Cardiometabolic Factors: A Multi-Center, Cross-Sectional, Clinical Study (https://pubmed.ncbi.nlm.nih.gov/25986079/

Nina Teicholz had an opinion piece published in the Wall Street Journal on May 30, discussing the USDA dietary guidelines that have largely ignored a massive body of evidence supporting a Very Low Carbohydrate Diet for obesity and diabetes. She cites many studies that have been ignored by the USDA dietary guidelines committee. Here is here opening statement.

“Americans with obesity, diabetes, heart disease and other diet-related diseases are about three times more likely to suffer worsened outcomes from Covid-19, including death. Had we flattened the still-rising curves of these conditions, it’s quite possible that our fight against the virus would today look very different.”

You can read the full article here:

https://www.wsj.com/articles/a-low-carb-strategy-for-fighting-the-pandemics-toll-11590811260

But think about that simple statement, THREE TIMES MORE LIKELY TO SUFFER WORSENED OUTCOMES FROM COVID-19. Yet these conditions are highly responsive to lifestyle interventions that not only mitigate obesity, insulin resistance and high blood pressure, but also enhance immune function.

More from Teicholz’s opinion piece:

“Other studies have found that dietary changes can rapidly and substantially improve cardiovascular risk factors, including conditions like hypertension that are major risk factors for worsened Covid-19 outcomes. A 2011 study in the journal Obesity on 300 clinic patients eating a very low-carbohydrate diet saw blood pressure quickly drop and remain low for years. And a 2014 trial on 148 subjects, funded by the National Institutes of Health, found a low-carb diet to be “more effective for weight loss and cardiovascular risk factor reduction” than a low-fat control diet at the end of the 1-year experiment.“

In a recent letter to the editor published in the journal METABOLISM, Dr. Casey Means points out:

A diagnosis of diabetes has been a key indicator of the severity of
COVID-19, and in this regard, the virus has relentlessly highlighted our
global Achilles heel of metabolic dysfunction, and points to a prime opportunity
to fight back.
That fight, however, is not going to be won with Clorox, Purell,
masks, or anti-IL-6 drugs. The fight will only be won through a serious
commitment to improving everyone’s foundational metabolic health,
starting with the lowest hanging evidence-based fruit: dietary and lifestyle
interventions.

Read the full letter here: https://www.metabolismjournal.com/article/S0026-0495(20)30118-9/pdf

In 2 pages the letter describes multiple benefits of better glucose control relative to COVID -19 infection and the immune system as well as reduction of factors that lead to cytokine storm (terminal event for many COVID-19 patients). The letter also discusses the benefit of reducing environmental toxins (discussed in previous posts about COVID-19 and other health problems) that would likely benefit COVID-19 patients.

Research published April 18th, 2020 found that patients exposed to
highest amount of environmental nitrogen dioxide (NO2) had increased
risk of death fromCOVID-19, and that long-term exposure to this pollutant
may be one of the most important contributors to fatality by
compounding lung inflammation [20].

Minimizing exposure to environmental
pollutants may serve a role in quelling the underlying pro-inflammatory
state that characterizes metabolic disease and COVID-19 associated
cytokine storms.

Other environmental toxins, including persistent organic pollutants
(POPs) found in air, water, and food generated from pesticides
and industrial chemicals, are also strongly implicated in the pathogenesis
of metabolic syndrome; promoting “clean living,” toxin-avoidant
strategies for patients as simple as emphasizing organic foods, home
air purification, and non-toxic home supplies could be considered, although
the clinical utility of these measures in the acute setting is unknown
[21].

In discussing the white elephant in the room he states:

What is starkly missing is the clear, simple, and strong recommendation for no added
sugar or ultra-refined carbohydrates, both of which are known drivers
of postprandial hyperglycemia and inflammation. As a medical community, we must not miss the opportunity to serve patients with straightforward, evidence-based nutritional and lifestyle strategies to assist in glycemic control.

I would encourage you to follow the link and read the 2 pages supported by multiple peer-reviewed references.

Evidence based nutritional and lifestyle strategies, so often discussed on this website include:

  1. Avoid alcohol consumption (alcohol wreaks havoc with your immunity)
  2. Get plenty of sleep (without adequate sleep your immune system does not work well )
  3. Follow good sleep habits
  4. Exercise, especially out of doors in a green space, supports the immune system
  5. Get some sunshine and make sure you have adequate Vitamin D levels.
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)

If you have obesity, diabetes or pre-diabetes the Very Low Carbohydrate version of the anti-inflammatory diet linked above would be the fastest and most effective intervention you can immediately employ to reduce your risk of succumbing to COVID-19. (Of course wear a mask, follow good hygiene with hand-washing frequently, and practice social distancing)

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

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COVID-19: Hydroxychloroquine and Chloroquine, BAD NEWS.

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The most comprehensive study on the use of these 2 drugs, including 96,032 patients in multiple hospitals and multiple countries shows increased risk of death with either of these two drugs in patients hospitalized with COVID-19. This was a retrospective study but offers the most amount of data to date on the issue of clinical efficacy and risk. You can read the full article https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31180-6/fulltext.

TreatmentDeath rateventricular arrhythmia
No drug9.30%0.30%
Hydroxychloroquine18%6.10%
Hydroxychloroquine plus Macrolide23.80%8.10%
Chloroquine16.40%4.30%
Chloroquine plus Macrolide22.20%6.50%
Macrolide is an antibiotic like Zithromax.
Differences between no drug and all drug treatment categories statistically significant.

This was not a randomized prospective controlled clinical trial. However the data were adjusted for:

age, sex, race or ethnicity, body-mass index, underlying cardiovascular disease and its risk factors, diabetes, underlying lung disease, smoking, immunosuppressed condition, and baseline disease severity.

So far it is the best information we have available.

There have been many physicians who have supported the use of these drugs without randomized controlled trials based on anecdotal reports in the medical literature. Given the desparate situation without a known effective drug that is understandable.

The authors note:

The absence of an effective treatment against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has led clinicians to redirect drugs that are known to be effective for other medical conditions to the treatment of COVID-19. Key among these repurposed therapeutic agents are the antimalarial drug chloroquine and its analogue hydroxychloroquine, which is used for the treatment of autoimmune diseases, such as systemic lupus erythematosus and rheumatoid arthritis.

However, the use of this class of drugs for COVID-19 is based on a small number of anecdotal experiences that have shown variable responses in uncontrolled observational analyses, and small, open-label, randomised trials that have largely been inconclusive.

 The combination of hydroxychloroquine with a second-generation macrolide, such as azithromycin (or clarithromycin), has also been advocated, despite limited evidence for its effectiveness.

This study is an important milestone, disappointing but illustrative of a common phenomenon in medicine.

Previous warnings about potential lethal heart rhythm issues were viewed with skepticism by armchair pundits claiming that there was not much data on sudden death related to use of these widely used drugs. Those pundits failed to understand that sudden death caused by prolonged QT interval (effect of these and many other drugs) cannot be diagnosed without an EKG during the event. When this occurs outside the hospital setting, or even in the hospital without a continuous EKG monitor on the patient, it goes unrecognized.

An important dictum in medicine is “first do no harm” (primum non nocere).

In the meantime, we do know what reduces risk:

Test/Trace/Isolate, social distance, MASKS4ALL, wash hands frequently, disinfect surfaces, show consideration for others. To understand why and how these measures can make a big difference you can go to this website. https://www.erinbromage.com/

In addition you can read a great article about the same topic here. https://www.newyorker.com/science/medical-dispatch/amid-the-coronavirus-crisis-a-regimen-for-reentry

I will close with the sermon on lifestyle and COVID-19.

  1. Avoid alcohol consumption (alcohol wreaks havoc with your immunity)
  2. Get plenty of sleep (without adequate sleep your immune system does not work well )
  3. You must follow good sleep habits
  4. Exercise, especially out of doors in a green space, supports the immune system
  5. Get some sunshine and make sure you have adequate Vitamin D levels.
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

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COVID-19 Sweden vs Other Countries

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5/21/2020 deaths/ million 7 day running average doubling time
cumulative deaths/million/day days
SWEDEN 379 3.3 46
Norway 43.6 0.13 241
Finland 54.9 0.52 138
Denmark 95.6 0.49 120
USA 282 4.02 49
NZ 4.3 0 598
stay home test-trace leadership
isolate example
SWEDEN no yes ?
Norway yes yes good
Finland yes yes good
Denmark yes yes good
USA late/variable POOR poor
New Zealand yes excellent excellent

Sweden was a source of controversy for the choice against instituting a stay-home policy. As you compare Sweden with other Scandinavian countries above you will see a dramatic difference in deaths per million (cumulative), running 7 day average deaths per million per day, and doubling time. The higher the doubling time (in days) the more a country has slowed the spread. New Zealand is the obvious winner. Early and aggressive action, effective test/trace/isolate, excellent leadership and example by the president are the hallmarks of success in New Zealand. Of course New Zealand is a small island with minimal international business and tourism so the comparison is not fair. HOWEVER, their success and strategy are obvious.

The US failed (and continues to fail) on test/trace/isolate despite the bluster and misrepresentations from the Whitehouse. California and Washington instituted early measures with respect to stay-home but without adequate test kits all of US states have been unable to execute the test/trace/isolate strategy proven effective in other countries. President Trump promised California 100,000 nasal swabs per week three weeks ago. They have not arrived. (California Department of Public Health)

Thus comparing USA to Sweden we see that with adequate social distancing, test/trace/isolate, Sweden did almost as well (or as poorly) as the US where stay at home was employed on a variable time line and to different degrees between the states.

You can review worldwide data, download spreadsheets, choose countries for comparison here.

Test/Trace/Isolate + Social distance + Masks4all + cooperation = SUCCESS

Had the US responded early and effectively, stay-home could have ended very quickly and safely with much less economic disruption.

Poor Management = inadequate Test/Trace/Isolate and other measures.

The New England Journal of Medicine published an article discussing the failure of the
USA relative to Test/Trace/Isolate.

Failing the Test — The Tragic Data Gap Undermining the U.S. Pandemic Response

 

The importance of  Reviving the US CDC after annual cuts by the Trump Administration is discussed here.

On March 25 the NEJM published an editorial on responding to the pandemic.

We did not follow the recommendations.

The AMERICAN ENTERPRISE INSTITUTE, a conservative think-tank, published a comprehensive Roadmap to Reopening.

Unfortunately we have not followed that roadmap.

So boost your immune system and meet the challenge with your personal behavior. Be smart.

  1. Avoid alcohol consumption (alcohol wreaks havoc with your immunity)
  2. Get plenty of sleep (without adequate sleep your immune system does not work well )
  3. You must follow good sleep habits
  4. Exercise, especially out of doors in a green space, supports the immune system
  5. Get some sunshine and make sure you have adequate Vitamin D levels.
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

 

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COVID-19: ARDS, CYTOKINE STORM, and GLUTATHIONE

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My good friend Dr. Deborah Gordon recently sent me a terrific article on an Integrative Medicine Approach to Covid-19. It confirmed much of what I have discussed about COVID-19 and provides 383 scientific references (many of which were cited in my previous posts). Thank you Dr. Deborah!

In my last post I promised to write about glutathione and cytokine storm.

Cytokines are proteins made by our immune system. When our body suffers an infection, cytokines act as essential signaling proteins that produce a defensive inflammatory response. In a cytokine storm the usual regulatory process that helps resolve inflammation becomes disturbed and self destruction can occur.

With COVID-19 this can happen in any organ of the body but frequently starts in the lungs, resulting in ARDS (Acute Respiratory Distress Syndrome).

In most clinical contexts the mortality rate of ARDS is 40-45%. In the context of COVID-19 it is 80-90 % lethal in most clinical reports (twice the usual mortality rate for ARDS). However, the ICU doctors in the Northwell Hospital system in NYC have been using NAC (n-Acetylcysteine).

While using NAC as part of their treatment protocol of COVID-19 associated ARDS, they are getting 50% of patients off the ventilator with a significant reduction in mortality rates compared to previous reports (personal communication with a Northwell physician and also mentioned in the Review Article cited above.)

This drug (also available as a dietary supplement) has been used for decades to treat acetaminophen (APAP) overdose (Tylenol brand name, also called paracetamol in Europe). If not treated early APAP overdose commonly causes death from liver failure.

Chronic acetaminophen toxicity is the most common cause of liver failure leading to liver transplant in the US.

How does this treatment  with NAC work in the setting of APAP overdose?

“When paracetamol is taken in large quantities, a minor metabolite called N-acetyl-p-benzoquinone imine (NAPQI) accumulates within the body. It is normally conjugated by glutathione, but when taken in excess, the body’s glutathione reserves are not sufficient to deactivate the toxic NAPQI. This metabolite is then free to react with key hepatic enzymes, thereby damaging liver cells. This may lead to severe liver damage and even death by acute liver failure.”

NAC (n-acetylcysteine) provides cysteine, one of the three amino acids that make up glutathione.

“glutathione synthesis is primarily controlled by the cellular level of the amino acid cysteine, the availability of which is the rate-limiting step.”

So by providing a source of cysteine, the body produces more glutathione which can detoxify the liver damaging metabolites of APAP.

Glutathione is our MASTER ANTI-OXIDANT. Since a cytokine storm involves an overwhelming amount of oxidative stress, glutathione is obviously important.

Clinical research in the 1990s established that the lungs of patients with ARDS are very deficient in glutathione.

A profound 20 fold reduction was confirmed in this study.

“Glutathione is a tripeptide that is able to react with and effectively neutralize oxidants, such as hydrogen peroxide. The present study found that the alveolar epithelial lining fluid of patients with ARDS was deficient in total glutathione compared with that of normal subjects (31.5 ± 8.4 versus 651.0 ± 103.1 µM, p = 0.0001) and patients with cardiogenic pulmonary edema (31.5 ± 8.4 versus 154.1 ± 52.4 µM, p = 0.001). In addition, a greater percentage of total glutathione was in the oxidized form in patients with ARDS compared with normal subjects (30.6 ± 6.1 versus 6.4 ± 2.9%, p = 0.03). This deficiency of reduced glutathione in the alveolar fluid may predispose these patients to enhanced lung cell injury.

Subsequent studies of humans with ARDS on ventilators showed clinical benefit by increasing glutathione levels with NAC.

“In our controlled clinical trials with NAC we found that patients with ARDS have depressed plasma and red cell glutathione concentrations, that these levels are substantially increased by therapy with intravenous NAC and there are measurable clinical responses to treatment with regard to increased oxygen delivery, improved lung compliance and resolution of pulmonary edema.”

Despite these findings decades ago, the use of NAC for ARDS has not been widely adopted. But it would make sense to employ this inexpensive medication, widely used for APAP overdose, for ARDS and in particular for cytokine storm caused by COVID-19.

Oxidative stress decreases glutathione levels and if these levels reach a critically  low level in tissues, organ damage can ensue rapidly. Cytokine storm is the extreme example.

Chronic alcohol abuse also decreases protective glutathione levels in the lung.

In my recent posts on COVID-19 I have pointed out that alcohol (even 2 drinks) suppresses the immune system for at least a few days. Alcohol consumption is a double hit, first as an immune suppressant, then as a major source of oxidative stress and reduction in protective glutathione levels. Two glasses of wine tonight followed by a COVID-19 sneeze in your face the next day could be the difference between an effective immune response (mild symptoms) versus an overwhelming life threatening infection!

Likewise, one night of inadequate sleep (which immediately suppresses immunity) followed by a COVID sneeze in your face the next day could have the same deleterious effect.

Below is a chart from the review article mentioned at the start of this post. Notice the top line states “ADDRESS SLEEP, STRESS, DIET, SUGAR, ALCOHOL”

If you have been reading my posts on COVID-19, you have heard this before.

integrative medicine chart

Notice the second row in the chart with escalating doses of NAC as intensity of disease increases. When cytokine storm hits NAC dose recommendations peak and glutathione (available for IV administration) is recommended. IV glutathione surprisingly is not part of most hospital formularies and I have never seen it used in a hospital setting. Functional medicine physicians sometimes use it outside of the hospital setting. IV glutathione has become a sexy and lucrative office procedure in some functional medicine practices.

NAC has high bioavailability, meaning it is absorbed well in our gut. So oral supplementation can rapidly and effectively increase levels of glutathione in the body. IN FACT, treatment of acetaminophen overdose in the ER typically begins with oral NAC (often administered through a naso-gastric feeding tube, passed through the nose and into the stomach) Doses are often calculated by the regional poison control center (available by phone 24/7/365) and subsequent doses follow a standard protocol based on weight.

I would encourage you to read through this COVID-19 INTEGRATIVE MEDICINE review article.

It is thick with science but you might be surprised by how much you understand and learn.

In the chart above there is specific mention of Vitamin C supplementation in escalating doses as degree of illness increases. Vitamin C is an important anti-oxidant and in that sense is a glutathione sparing agent helping to mitigate glutathione depletion.

Other important factors mentioned in the article and the chart above include items mentioned here in previous posts: ZINC, ZINC IONOPHORES, phytochemicals (quercitin, EGCg, curcumin), Vitamin D, exercise, sleep, stress reduction, sunshine.

So I will close this post the way I have closed on many posts related to COVID-19.

Support your immune system.

  1. Avoid alcohol consumption (alcohol wreaks havoc with your immunity)
  2. Get plenty of sleep (without adequate sleep your immune system does not work well )
  3. Follow good sleep habits
  4. Exercise, especially out of doors in a green space, supports the immune system
  5. Get some sunshine and make sure you have adequate Vitamin D levels.
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system
  8.  Eliminate sugar-added foods and beverages from your diet, sugar increases inflammation, contributes to metabolic dysfunction and impairs immunity.

In a future post I will describe my PERSONAL approach to dietary supplements in the context of COVID-19. I will also discuss the issue of an ADVANCED DIRECTIVE, in case you are hospitalized.

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

Glutathione review links are below:

Glutathione!

Mitochondrial Glutathione, a key survival antioxidant

Glutathione: overview of its protective roles, measurement, and biosynthesis

 

 

 

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ZINC, ionophores, supplements and COVID-19

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ZINC is an essential mineral present in many foods. It is also available as a dietary supplement. Zinc in combination with a zinc ionophore (which helps zinc enter human cells) can inhibit viral replication in human cells. It does this by blocking RNA POLYMERASE, which is necessary for replication of the CORONA VIRUS.

Zinc is required for proper functioning of more than 300 important enzymes in our bodies and plays an essential role in:

Immune Function

Protein Synthesis

Wound Healing

DNA Synthesis

Normal Growth and Devlopement During Pregnancy, Childhood and Adolescence

A daily intake of ZINC IS REQUIRED because the human body has no specialized storage system.

“Zn is an essential trace element for all organisms. In human subjects body growth and development is strictly dependent on Zn. The nervous, reproductive and immune systems are particularly influenced by Zn deficiency, as well as by increased levels of Zn. The relationship between Zn and the immune system is complex, since there are four different types of influence associated with Zn. (1) The dietary intake and the resorption of Zn depends on the composition of the diet and also on age and disease status. (2) Zn is a cofactor in more than 300 enzymes influencing various organ functions having a secondary effect on the immune system. (3) Direct effects of Zn on the production, maturation and function of leucocytes. (4) Zn influences the function of immunostimulants used in the experimental systems.”

Zinc deficiency is very common amongst the elderly which may contribute to the high death rate for COVID-19 for folks 65 and older.

From the NIH:

“some evidence suggests that zinc intakes among older adults might be marginal. An analysis of NHANES III data found that 35%–45% of adults aged 60 years or older had zinc intakes below the estimated average requirement of 6.8 mg/day for elderly females and 9.4 mg/day for elderly males. When the investigators considered intakes from both food and dietary supplements, they found that 20%–25% of older adults still had inadequate zinc intakes“

You can read more about Zinc here.

Here is a list of zinc levels in various foods:

Table 2: Selected Food Sources of Zinc [11]
Food Milligrams (mg)
per serving		 Percent DV*
Oysters, cooked, breaded and fried, 3 ounces 74.0 673
Beef chuck roast, braised, 3 ounces 7.0 64
Crab, Alaska king, cooked, 3 ounces 6.5 59
Beef patty, broiled, 3 ounces 5.3 48
Lobster, cooked, 3 ounces 3.4 31
Pork chop, loin, cooked, 3 ounces 2.9 26
Baked beans, canned, plain or vegetarian, ½ cup 2.9 26
Breakfast cereal, fortified with 25% of the DV for zinc, 1 serving 2.8 25
Chicken, dark meat, cooked, 3 ounces 2.4 22
Pumpkin seeds, dried, 1 ounce 2.2 20
Yogurt, fruit, low fat, 8 ounces 1.7 15

When CNN discussed the importance of ZINC relative to COVID-19, zinc supplements disappeared from the shelves in pharmacies and health food stores. Zinc supplements are still out of stock in most on-line supplement sites.

Hydroxychloroquine and Chloroquine are anti-malarial drugs (also used to treat Lupus, Rheumatoid Arthritis) that act as Zinc Ionophores.

So far, all the studies on the use of anti-malarial drugs for COVID-19 have been disappointing with no randomized/controlled trials demonstrating clinical benefit (no reduction in death rates). But NONE OF THESE STUDIES CHECKED ZINC LEVELS OR PROVIDED ZINC SUPPLEMENTATION!!!

In addition, as discussed before, these anti-malarial drugs can cause significant (and rarely lethal) side effects.

There are dietary sources of zinc ionophores that do not require a prescription.

Quercitin and EGCG (Epigallocatechin-gallate) both act as zinc ionophores in-vitro (in cell cultures).

“Dietary plant polyphenols such as the flavonoids quercetin (QCT) and epigallocatechin-gallate act as antioxidants and as signaling molecules. Remarkably, the activities of numerous enzymes that are targeted by polyphenols are dependent on zinc. We have previously shown that these polyphenols chelate zinc cations and hypothesized that these flavonoids might be also acting as zinc ionophores, transporting zinc cations through the plasma membrane. To prove this hypothesis, herein, we have demonstrated the capacity of QCT and epigallocatechin-gallate to rapidly increase labile zinc in mouse hepatocarcinoma Hepa 1-6 cells as well as, for the first time, in liposomes.”

Quercitin is the most abundant dietary polyphenol.

Foods Quercetin
(mg/100g)
capers, raw 234[6]
capers, canned 173[6]
dock like sorrel 86[6]
radish leaves 70[6]
carob fiber 58[6]
dill 55[8]
cilantro 53[6]
Hungarian wax pepper 51[6]
fennel leaves 49[6]
onion, red 32[6]
radicchio 32[6]
watercress 30[6]
kale 23[6]
chokeberry 19[6]
bog blueberry 18[6]
cranberry 15[6]
lingonberry 13[6]
plums, black 12[6]

It is also available as a dietary supplement.

EGCG is found in green tea but has low bioavailability.

EGCG in very high doses can cause liver toxicity. From WIKIPEDIA:

A 2018 review showed that excessive intake of EGCG may cause liver toxicity.[15] In 2018, the European Food Safety Authority stated that daily intake of 800 mg or more could increase risk of liver damage.[16] The degree of toxicity varies by person, suggesting that it is potentiated by genetic predisposition and the diet eaten during the period of ingestion, or other factors.[17]

Zinc is an essential mineral but can be toxic when taken at high doses.

From the NIH:

“Zinc toxicity can occur in both acute and chronic forms. Acute adverse effects of high zinc intake include nausea, vomiting, loss of appetite, abdominal cramps, diarrhea, and headaches [2]. One case report cited severe nausea and vomiting within 30 minutes of ingesting 4 g of zinc gluconate (570 mg elemental zinc) [84]. Intakes of 150–450 mg of zinc per day have been associated with such chronic effects as low copper status, altered iron function, reduced immune function, and reduced levels of high-density lipoproteins [85]. Reductions in a copper-containing enzyme, a marker of copper status, have been reported with even moderately high zinc intakes of approximately 60 mg/day for up to 10 weeks [2]. The doses of zinc used in the AREDS study (80 mg per day of zinc in the form of zinc oxide for 6.3 years, on average) have been associated with a significant increase in hospitalizations for genitourinary causes, raising the possibility that chronically high intakes of zinc adversely affect some aspects of urinary physiology [86].

The FNB has established ULs for zinc (Table 3). Long-term intakes above the UL increase the risk of adverse health effects [2]. The ULs do not apply to individuals receiving zinc for medical treatment, but such individuals should be under the care of a physician who monitors them for adverse health effects.”

 

Table 3: Tolerable Upper Intake Levels (ULs) for Zinc [2]
Age Male Female Pregnant Lactating
0–6 months 4 mg 4 mg
7–12 months 5 mg 5 mg
1–3 years 7 mg 7 mg
4–8 years 12 mg 12 mg
9–13 years 23 mg 23 mg
14–18 years 34 mg 34 mg 34 mg 34 mg
19+ years 40 mg 40 mg 40 mg 40 mg
 

 

Most zinc supplements come in doses of 25-50 mg of elemental zinc.

There are potential interactions between medications and zinc. The following medications decrease the absorption of zinc.

Quinolone antibiotics (including Cipro)

Tetracycline antibiotics.

Penicillamine (used to treat Rheumatoid Arthritis, a known risk factor for bad outcomes in COVID-19)

Thiazide diuretics (chlorthalidone, hydrochlorthiazide) and these can lead to chronic zinc deficiency. They are used to treat hypertension which is a known risk factor for bad outcomes in COVID-19.

In the setting of COVID-19, a Paleo/Ancestral TYPE anti-inflammatory diet is VERY IMPORTANT.

There are many reasons including the following benefits of such a diet:

  1.  High intake of zinc and foods containing quercetin and EGCG
  2.  Avoidance of foods high in phytic acid which blocks the absorption of zinc and many other essential minerals such as magnesium, calcium, and iron.
  3.  Improved blood sugar control (diabetes and insulin resistance increase the risk of death from COVID-19)
  4.  Improved blood pressure (hypertension increases the risk of death from COVID-19)
  5.  Avoidance of alcohol which increase risk of death from COVID-19 by impairing immune function.

A physician friend and colleague recently wrote a post that documents the benefits of a carbohydrate restricted, whole foods diet, with elimination of processed and sugar-added foods and beverages. I highly recommend you read it here.

With regards to maintaining a properly functioning immune system a few simple lifestyle habits are essential,

  1. Avoid alcohol consumption (alcohol wreaks havoc with your immunity)
  2. Get plenty of sleep (without adequate sleep your immune system does not work well )
  3. You must follow good sleep habits
  4. Exercise, especially out of doors in a green space, supports the immune system
  5. Get some sunshine and make sure you have adequate Vitamin D levels.
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system

Finally, think about ZINC and ZINC IONOPHORES  relative to diet and personal habits. While there have not been studies using zinc in combination with zinc ionophores (and there likely will never be) relative to COVID-19, all available scientific information about the relationship between corona virus replication and these two items indicates that in combination they might provide benefit. It is a shame that the studies in progress have not considered zinc status in patients receiving the anti-malarial drugs.

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

 

 

 

 

 

 

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Stanford Study on Santa Clara County: Very questionable conclusions

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My last post discussed a study from Stanford that suggested 50-85 times greater Infection Rate (IR) compared to the Case Rate (CR) in Santa Clara County. The Wall Street Journal published a discussion of this Study (which has not yet been peer reviewed) claiming that it was good evidence of a much lower fatality rate for COVID-19. Turns out that study was deeply flawed. The test used likely had a false positive rate of 13%, not 0.5% assumed by the authors. That alone makes the conclusions completely bogus. In addition, the study population was not truly a random sample and likely had significant selection bias. For a complete expose watch this:

One would expect something better from Stanford, but like I said, this was not yet peer reviewed.

“This article is a preprint and has not been peer-reviewed [what does this mean?]. It reports new medical research that has yet to be evaluated and so should not be used to guide clinical practice.”

But the Wall Street Journal reported on it in a favorable way, not revealing that one of the authors of the study was also the author who wrote the WSJ article!

A brief note about false positives and false negatives.

Suppose you are looking at a population of 1,000,000 people with an infection rate of 1% (990,000 do not have the disease)

Assume a sensitivity of 93% (the test is positive in 93% of true positives)

Assume a specificity of 96% (false positive rate of 4%)

If you test everyone, 9300 of the 10,000 true cases will be detected, 700 of the cases will not be detected.

BUT 40,000 false positives will be found for a total of 49,300 positives. You will publish an infection rate of 4.93% while the real infection rate is only 1%.

Statistics are tricky. The sensitivity and specificity of a test are extremely important.

Be careful about what you read. We all would like to be reassured that it would be safe to relax restrictions but we still do not yet know  the true IFR. The true infection rate depends on widespread testing with an accurate test and we have not yet done that.

Besides the economic downturn associated with shelter in place, there are valid clinical concerns about the damage being caused (depression, anxiety, suicide, spousal abuse, child abuse, reluctance to call 911 for a real emergency, etc..) We will need to return to less restrictions in an incremental way based on regional circumstances (NYC not the same as Northern California).

For a detailed discussion about how and when we should relax restrictions read this.

There has been allot of comparing apples with oranges in the social media. People keep trying to compare COVID-19 to the flu. They are very different with respect to the fatality rate and ease of transmission. (In addition, whereas we have had a vaccine for Influenza A and B, we do not have one for COVID-19 or any other Corona Virus)

Review:

Case Rate (CR) is the # of known cases based on nasal swab PCR test divided by population.

Infection Rate (IR) is the actual # of cases divided by population. This is estimated by performing a reliable serology test on a large random sample of people, testing for infection by measuring antibodies (there are a few tests available but their sensitivity and specificity remain controversial and crucial)

A recent analysis comparing the 2009 H1N1 influenza A pandemic to COVID 19 suggested this:

Case Fatality Rate Infection Fatality Rate
2009 H1N1 Virus (flu) 0.1% to 0.2% 0.02%
COVID-19 New York 8% 0.50%

Some folks on social media have been comparing the CFR of the flu to the IFR of COVID-19. That is comparing apples to oranges.

The data in the table above are based on what appears to be the most recent and reliable information from New York City. The data on 2009 H1N1 is reported here.

In the old news clip below, 2920 adult deaths associated with 12 million cases of H1N1 calculates out to a 0.02% IFR which is exactly the same IFR described in the study linked above..

In this same report and in other discussions of H1N1 it was clear that children were more severely effected compared to COVID-19.

The table above would indicate that the IFR (infection fatality rate) of COVID-19 IS 25 TIMES GREATER than the IFR of the 2009 H1N1 Influenza A pandemic. The CFR of COVID-19 IN NEW YORK CITY is 40 times greater. This represents a much greater difference than the relative fatality rates suggested by the highly questionable conclusions of the Stanford Study of Santa Clara County.

There is a possibility that the New York City strain of COVID-19 might be more lethal than the strain of COVID-19 on the West Coast. That suggestion is PURELY SPECULATIVE and so far there is no data to support it. This possibility has been suggested because  NYC and New Jersey hospitals are much closer to capacity with COVID-19 compared to the West Coast experience and there are portable refrigerator truck morgues outside of hospitals in NYC and New Jersey where the local morgues filled up weeks ago. Again I would point to the major differences of the apparent CFRs between various countries and regions within countries which have not yet been explained (as discussed in my last post).

We have much more to learn, we need more testing (both nasal PCR and blood serology) to understand the spread and lethality of this disease. Those in the social media who claim we already have herd immunity are spewing nonsense. Herd immunity requires > 80% infection rate. Our measured IRs are highest in NYC (about 15%) and much lower in other areas where “reliable” serology has been performed.

One great failure in our country has been the prolonged lack of adequate testing. Shelter-in-place should have been a time-out to collect data and access where we are. That can only happen with reliable wide-spread testing. To AVOID overwhelming our hospitals and health care workers we must identify cases, trace contacts, isolate positives and isolate contacts. Isolation would ideally not be at home where the disease could easily spread to the entire household. Isolation at home is only reasonable when that home has a separate bedroom and bathroom for the infected person AND the household follows strict isolation and hygiene.

We must all recognize that the primary objective of shelter in place is to avoid overwhelming the health care system. Eventually, unless a treatment or vaccine becomes available, the disease will infect most of our population before we reach herd immunity. To return to economic activity and a more “normal life” we will necessarily accept a large number of deaths, primarily but not exclusively amongst the elderly and infirm. Generally it would seem reasonable to begin incrementally relaxing restrictions in areas of low impact, wearing masks, working from home where possible, avoiding public gatherings especially in confined spaces, and following good personal hygiene. So far the best information on risk (of death) appears to be in the table above, stratifying for age and risk factors.

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

 

 

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Follow up to Letter from Front Line Doctor post and more

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After posting the letter from an ER doc who eloquently expressed the danger, concerns, and most importantly, call for action I realized that some explanation for the lay person is necessary.

Intubation is the placement of a breathing tube into the windpipe for a person in respiratory failure. During the procedure the doctor and all providers in the immediate area are in a very high risk situation because the droplets filled with billions of virus can become aerosolized. I previously explained the difference between spread by droplet vs aerosol. Droplets fall to the floor and surfaces where virus can be infectious for hours. But when aerosolized, the virus remains suspended in the air for hours and anyone entering the area can become infected by simply breathing the air.

During intubation the doctor has his/her face inches from the patients mouth and nose. During this procedure droplets can become aerosolized. Even wearing a perfectly fitting N95 mask, goggles, gown, gloves the doctor (and those assisting) is/are not completely protected.

I received a warning letter from an ENT surgeon at Stanford, warning colleagues about cases of ENT and Neuro-surgery (endoscopic surgery through the nose) where despite FULL PPE, all practitioners in the operating room became infected and  surgeons have died. The ENT surgeon warned that PPE with N-95 mask was not fully protective and recommended PAPRs be used (Powered, Air Purifying Respirators.) Here is what the surgeon reported he received from his international colleagues:

“All 14 people who came in and out of the OR during that case became infected. He saw this repeat with other endoscopic cases

He has also shared that a significant number of doctors who died in China were ENTs and Ophthalmologists, possibly due to the high viral shedding from the nasal cavity. This has now been confirmed in the media as well.[i]

[i] https://www.bloomberg.com/news/articles/2020-03-17/europe-s-doctors-getting-sick-like-in-wuhan-chinese-doctors-say?fbclid=IwAR2ds9OWRxQuMHAuy5Gb7ltqUGMZNSojVNtFmq3zzcSLb_bO9aGYr7URxaI”

All 14 people who entered and left the operating room during the surgery became infected despite wearing PPE!!!!!!!!!!

“we have additionally heard from Iran that at least 20 ENTs are currently hospitalized with COVID-19, with 20 more in isolation at home.” 

Although SARs had a higher mortality rate, IT WAS NOT AS CONTAGIOUS.

This demonstrates how contagious this virus can be, and that was early on in China and Iran, before it mutated. Mutations can make the virus more contagious and more lethal. There has already been a SECOND STRAIN IDENTIFIED.

In my career I have performed more than 10,000 intubations. Many under emergency circumstances. Donning full PPE correctly takes time and when in a hurry the N95 mask may not be perfectly fitted. (WATCH THE VIDEO BELOW)

Although I have intubated people with sepsis and TB under emergency conditions, I have never been exposed to the level of danger that doctors and other providers around the world are now experiencing. The PPE (personal protection equipment) is already running short in hot zones. Many hospitals are a few days away from running out. MANY PROVDERS are reusing PPE that is not meant to be reused.

AS more doctors, nurses, and techs become infected (which is inevitable) there will be less personnel to care for patients so MORTALITY RATES WILL INCREASE.

This has not been factored into the epidemiologic models and projections.

Temporary emergency hospital tents are great, but useless without personnel. There is a limited # of ICU and ER doctors, nurses and techs. And they all need PPE.

That is why flattening the curve is so important.

That is why folks who ignore the behavioral guidelines are reckless and endangering others in the community and in hospitals.

We need to hear this every day from Doctors like FAUCI.

Misinformation from uninformed and anti-science politicians is tragically harmful.

EASTER WILL NOT BE MAGICAL.

Ventilators are useless without doctors, nurses and respiratory therapists to manage them. So production of ventilators is futile unless PPE are prioritized, WHICH HAS NOT YET HAPPENED. Shortages abound and the executive branch has not coordinated the private sector in addressing production and distribution. Instead leaving it up to the MARKET!

This has been described as a WAR, but we are not mobilizing the way we did during WW2. Mobilization requires central coordination, not bidding wars between states and hospitals for PPE, bleach and other sanitizers.

Here is the link to AN instructional video on donning PPE. Watch how long it takes and the steps required to achieve proper fit and seal for the N95 mask. Now imagine doing that while a patient is blue/hypoxic, or in cardiac and/OR respiratory arrest.

 

 

Later I will post practical precautions for groceries, mail, gas stations etc. A separate page on this website will document that.

I will also create a COVID 19 page with cut and pasted excerpts from documents as well as links to informative documents, videos and websites.

STAY SAFE.

I do not wish to create or contribute to panic, if you follow the recommendations of shelter in place and social distancing and follow good hygiene you and everyone around you will be MUCH SAFER. I merely want to emphasize why flattening the curve and following recommendations are so important. The more people comply, the shorter will be the time when we can prudently start to return incrementally to normal activity.

Testing still remains inadequate with backlogs of 10 days in hot zones. So the information we are getting on # of cases is almost 2 weeks behind what is out there and even if we had 45 minute turn around, the testing kits are being rationed. So we are just seeing the tip of the iceberg. And that will be the UNFORTUNATE situation for a while.

Although we have seen TOO LITTLE TOO LATE, we can still flatten the curve by following recommended practices. We can still save lives, prevent disability and suffering, and get to a point where we can return to a more “normal” life. The longer we wait for every state to institute necessary measures (Florida is an example of inadequate measures) the longer will be our restrictions.

Remember, you can boost your immune system by getting adequate restorative sleep, rest, exercise, sunshine, stress reduction and eating an anti-inflammatory diet. Avoid alcohol (which impairs your immune system) and quit smoking. You can help prepare your body to mitigate a cytokine storm by increasing in your cell membranes, the omega 3 marine fats (EPA and DHA) which are the precursors for RESOLVINS that help regulate the inflammatory response. The inflammatory response is protective but when out of control it can be lethal in the ICU or on your way to the hospital. Your body’s defense systems can be optimized by eating an anti-inflammatory diet rich in nutrients that support immunity and regulate inflammation. A healthy diet can only be beneficial. All of these measures can be practiced while sheltering in place and practicing social distancing.

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

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COVID19 UPDATE, UCSF CONFERENCE REPORTS FRIGHTENING INFORMATION

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On March 10 a panel discussion/conference of Infectious Disease and PANDEMIC experts convened at UCSF (University of California San Francisco). Here are the panelists.

  • Panelists
    • Joe DeRisi:  UCSF’s top infectious disease researcher.  Co-president of ChanZuckerberg BioHub (a JV involving UCSF / Berkeley / Stanford).  Co-inventor of the chip used in SARS epidemic.
    • Emily Crawford:  COVID task force director.  Focused on diagnostics
    • Cristina Tato:   Rapid Response Director.  Immunologist.
    • Patrick Ayescue:   Leading outbreak response and surveillance.  Epidemiologist.
    • Chaz Langelier:   UCSF Infectious Disease doctor

Unless bracketed, these are direct quotes of the panelists. This was forwarded to me by a physician friend whose colleague prepared it. The “I” refers to that colleague.

University of California, San Francisco BioHub Panel on COVID-19

March 10, 2020

  • Top takeaways 
    • At this point, we are past containment.  Containment is basically futile.  Our containment efforts won’t reduce the number who get infected in the US.  
    • Now we’re just trying to slow the spread, to help healthcare providers deal with the demand peak.  In other words, the goal of containment is to “flatten the curve”, to lower the peak of the surge of demand that will hit healthcare providers.  And to buy time, in hopes a drug can be developed. 
    • How many in the community already have the virus?  No one knows.
    • We are moving from containment to care.  
    • We in the US are currently where at where Italy was a week ago.  We see nothing to say we will be substantially different.
    • 40-70% of the US population will be infected over the next 12-18 months.  After that level you can start to get herd immunity.  Unlike flu this is entirely novel to humans, so there is no latent immunity in the global population.
    • [We used their numbers to work out a guesstimate of deaths— indicating about 1.5 million Americans may die.  The panelists did not disagree with our estimate.  This compares to seasonal flu’s average of 50K Americans per year.  Assume 50% of US population, that’s 160M people infected.  With 1% mortality rate that’s 1.6M Americans die over the next 12-18 months.]  
      • The fatality rate is in the range of 10X flu.
      • This assumes no drug is found effective and made available.
    • The death rate varies hugely by age.  Over age 80 the mortality rate could be 10-15%.  [See chart by age Signe found online, attached at bottom.]
    • Don’t know whether COVID-19 is seasonal but if is and subsides over the summer, it is likely to roar back in fall as the 1918 flu did
    • I can only tell you two things definitively.  Definitively it’s going to get worse before it gets better.  And we’ll be dealing with this for the next year at least.  Our lives are going to look different for the next year.

 

  • What should we do now?  What are you doing for your family?
    • Appears one can be infectious before being symptomatic.  We don’t know how infectious before symptomatic, but know that highest level of virus prevalence coincides with symptoms.  We currently think folks are infectious 2 days before through 14 days after onset of symptoms (T-2 to T+14 onset).
    • How long does the virus last?
      • On surfaces, best guess is 4-20 hours depending on surface type (maybe a few days) but still no consensus on this
      • The virus is very susceptible to common anti-bacterial cleaning agents:  bleach, hydrogen peroxide, alcohol-based.
    • Avoid concerts, movies, crowded places.
    • We have cancelled business travel.
    • Do the basic hygiene, eg hand washing and avoiding touching face.
    • Stockpile your critical prescription medications.  Many pharma supply chains run through China.  Pharma companies usually hold 2-3 months of raw materials, so may run out given the disruption in China’s manufacturing.
    • Pneumonia shot might be helpful.  Not preventative of COVID-19, but reduces your chance of being weakened, which makes COVID-19 more dangerous.
    • Get a flu shot next fall.  Not preventative of COVID-19, but reduces your chance of being weakened, which makes COVID-19 more dangerous.
    • We would say “Anyone over 60 stay at home unless it’s critical”.  CDC toyed with idea of saying anyone over 60 not travel on commercial airlines.
    • We at UCSF are moving our “at-risk” parents back from nursing homes, etc. to their own homes.  Then are not letting them out of the house.  The other members of the family are washing hands the moment they come in.
    • Three routes of infection
      • Hand to mouth / face
      • Aerosol transmission
      • Fecal oral route

 

 

  • What if someone is sick?
    • If someone gets sick, have them stay home and socially isolate.  There is very little you can do at a hospital that you couldn’t do at home.  Most cases are mild.  But if they are old or have lung or cardio-vascular problems, read on.
    • If someone gets quite sick who is old (70+) or with lung or cardio-vascular problems, take them to the ER.
    • There is no accepted treatment for COVID-19.  The hospital will give supportive care (eg IV fluids, oxygen) to help you stay alive while your body fights the disease.  ie to prevent sepsis.
    • If someone gets sick who is high risk (eg is both old and has lung/cardio-vascular problems), you can try to get them enrolled for “compassionate use” of Remdesivir, a drug that is in clinical trial at San Francisco General and UCSF, and in China.  Need to find a doc there in order to ask to enroll.  Remdesivir is an anti-viral from Gilead that showed effectiveness against MERS in primates and is being tried against COVID-19.  If the trials succeed it might be available for next winter as production scales up far faster for drugs than for vaccines.  [MoreI found online.]
    • Why is the fatality rate much higher for older adults?
      • Your immune system declines past age 50
      • Fatality rate tracks closely with “co-morbidity”, ie the presence of other conditions that compromise the patient’s health, especially respiratory or cardio-vascular illness.  These conditions are higher in older adults.
      • Risk of pneumonia is higher in older adults.

 

  • What about testing to know if someone has COVID-19? 
    • Bottom line, there is not enough testing capacity to be broadly useful.  Here’s why.
    • Currently, there is no way to determine what a person has other than a PCR test.  No other test can yet distinguish “COVID-19 from flu or from the other dozen respiratory bugs that are circulating”.
    • A Polymerase Chain Reaction (PCR) test can detect COVID-19’s RNA.  However they still don’t have confidence in the test’s specificity, ie they don’t know the rate of false negatives.
    • The PCR test requires kits with reagents and requires clinical labs to process the kits.
    • While the kits are becoming available, the lab capacity is not growing.
    • The leading clinical lab firms, Quest and Labcorp have capacity to process 1000 kits per day.  For the nation.
    • Expanding processing capacity takes “time, space, and equipment.”  And certification.   ie it won’t happen soon.
    • UCSF and UC Berkeley have donated their research labs to process kits.  But each has capacity to process only 20-40 kits per day.  And are not clinically certified.
    • Novel test methods are on the horizon, but not here now and won’t be at any scale to be useful for the present danger.

 

  • How well is society preparing for the impact?
    • Local hospitals are adding capacity as we speak.  UCSF’s Parnassus campus has erected “triage tents” in a parking lot.  They have converted a ward to “negative pressure” which is needed to contain the virus.  They are considering re-opening the shuttered Mt Zion facility.
    • If COVID-19 affected children then we would be seeing mass departures of families from cities.  But thankfully now we know that kids are not affected.
    • School closures are one the biggest societal impacts.  We need to be thoughtful before we close schools, especially elementary schools because of the knock-on effects.  If elementary kids are not in school then some hospital staff can’t come to work, which decreases hospital capacity at a time of surging demand for hospital services.
    • Public Health systems are prepared to deal with short-term outbreaks that last for weeks, like an outbreak of meningitis.  They do not have the capacity to sustain for outbreaks that last for months.  Other solutions will have to be found.
    • What will we do to handle behavior changes that can last for months?
      • Many employees will need to make accommodations for elderly parents and those with underlying conditions and immune-suppressed.
      • Kids home due to school closures
    • [Dr. DeRisi had to leave the meeting for a call with the governor’s office.  When he returned we asked what the call covered.]  The epidemiological models the state is using to track and trigger action.  The state is planning at what point they will take certain actions.  ie what will trigger an order to cease any gatherings of over 1000 people.

 

  • Where do you find reliable news?
    • The John Hopkins Center for Health Security site.   Which posts daily updates.  The site says you can sign up to receive a daily newsletter on COVID-19 by email.  [I tried and the page times out due to high demand.  After three more tries I was successful in registering for the newsletter.]
    • The New York Times is good on scientific accuracy.

 

 

  • Observations on China
    • Unlike during SARS, China’s scientists are publishing openly and accurately on COVID-19.
    • While China’s early reports on incidence were clearly low, that seems to trace to their data management systems being overwhelmed, not to any bad intent.
    • Wuhan has 4.3 beds per thousand while US has 2.8 beds per thousand.  Wuhan built 2 additional hospitals in 2 weeks.  Even so, most patients were sent to gymnasiums to sleep on cots.
    • Early on no one had info on COVID-19.  So China reacted in a way unique modern history, except in wartime.

 

  • Every few years there seems another:  SARS, Ebola, MERS, H1N1, COVID-19.  Growing strains of antibiotic resistant bacteria.  Are we in the twilight of a century of medicine’s great triumph over infectious disease?
    • “We’ve been in a back and forth battle against viruses for a million years.”
    • But it would sure help if every country would shut down their wet markets.
    • As with many things, the worst impact of COVID-19 will likely be in the countries with the least resources, eg Africa.  See article on Wired magazine on sequencing of virus from Cambodia.

So that is the synopsis provided by my friend’s colleague.

Unfortunately, the Trump administration has been dangerously incompetent in addressing-mitigating the public health and economic impact. Trump STILL HAS NOT DECLARED THIS A NATIONAL EMERGENCY!

Whitehouse spokespeople have stated Trump does not want to declare this an emergency because it would contradict his earlier statements that COVID19 is not a serious problem (he tweeted and stated it is less serious than the flu). If declared a NATIONAL EMERGENCY it would free up large amounts of money and resources for public health, FEMA, and economic assistance, yet it has not been done. INSTEAD, TRUMP is waiting for his son-in-law (who has no scientific training) to research COVID19 and make recommendations for national policy!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

SERIOUSLY???????????

This post and all posts are for informational, educational purposes and should not be taken as medical advice. Consult your health care practitioner for medical advise.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

 

 

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Depression, Food, Sunshine, Gut Microbiome

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A family member was admitted to a psychiatric hospital this year with a major depressive episode. For the sake of anonymity lets call her Margie. I investigated the hospital and found that the medical director, chief nursing officer and CEO had excellent credentials. I asked Margie about her food choices, opportunity for exercise and time outdoors. All of these were deplorable. The only opportunity to spend time outdoors was to go outside with the smoking group for 20 minutes twice per day (cigarette breaks). There was no exercise program or exercise opportunity other than walking the halls and walking up and down the stairs with the smoking group going to/from a smoking session. The only green leafy vegetable available was iceberg lettuce (minimal nutritional value). Food options included high sugar and high starch content items, with very few vegetables and fresh fruits. Sugar and refined carbohydrates contribute to inflammation and gut dysbiosis, both of which contribute to psychiatric illness.

Margie had insomnia and depression. These two problems travel together and feed on each other. The lack of outdoor light in the morning and presence of artificial light in the evening all contribute to disruption of  circadian rhythm, worsening depression and insomnia. Lack of exercise also contributes to both.

Here is an excerpt of a letter I sent to her treating psychiatrist with copies to the CEO, medical director and chief nursing officer.

I do have concerns about the lack of availability at XXXXXXXXX Hospital of two essential components to mental health, specifically nutritional support and exercise.

So far the dietician has not yet consulted with XXXXX. I called the dietary department to discuss my concerns that she has been served primarily nutritionally deplete starch and sugar laden foods with a minimum of vegetables, fruit, healthy fat and protein. I was told that the only green leafy vegetable available is lettuce and when I inquired about other vegetables the response was very limited. Bob in the dietary department was great and very receptive to my concerns but seems somewhat limited in the availability of appropriate nutrient dense food at XXXXXXXX.

In addition, Maria tells me that XXXXXXX has no exercise program or exercise facility for patients. The importance of exercise and nutrition has been discussed extensively in the psychiatry literature.

Enclosed are a few review articles and abstracts relevant to nutrition and exercise for in-patient psychiatry. I hope you find these useful and would consider making efforts along the lines of the author’s recommendations in these studies and review articles.

I found the review by Dr LaChance and Dr. Ramsey “Antidepressant foods: An evidence-based nutrient profiling system for depression” to be most informative. You are probably aware that Dr. Ramsey has presented many lectures at the annual meeting of the American Psychiatric Association. The authors of the other studies enclosed have also been well represented at that meeting.

Despite requesting a response from the Medical Director, Chief Nursing Officer, and CEO, I never received any communication in response to my concerns.

The concept of “NUTRITIONAL PSYCHIATRY” has received much attention in the psychiatry literature. This article was published in the World Journal of Psychiatry. Antidepressant foods: An evidence-based nutrient profiling system for depression.

The article discusses nutrients that are “related to the prevention and treatment of depressive disorders”

Here is a summary:

Twelve Antidepressant Nutrients relate to the prevention and treatment of depressive disorders: Folate, iron, long-chain omega-3 fatty acids (EPA and DHA), magnesium, potassium, selenium, thiamine, vitamin A, vitamin B6, vitamin B12, vitamin C, and zinc.

The highest scoring foods were bivalves such as oysters and mussels, various seafoods, and organ meats for animal foods. The highest scoring plant foods were leafy greens, lettuces, peppers, and cruciferous vegetables.

This description aligns with the anti-inflammatory diet that I recommend to patients.

This dietary approach provides essential nutrients for brain health but also provides for healthy diversity in the gut microbiome,.

The relationship between psychiatric illness and the gut microbiome has been extensively reviewed in the medical literature.

Source of image:

Frontiers in Integrative Neuroscience, 11 September 2018 | https://doi.org/10.3389/fnint.2018.00033

This complicated picture depicts the interaction between food, gut microbiome, immune system, inflammation, endocrine system (stress response mediated by the hypothalamic pituitary adrenal axis), nervous system, neuro-transmitters including serotonin (the target of many ante-depressant medications). BBB is the blood brain barrier. ENS is the enteric nervous system. SCFAs are short chain fatty acids, very important for health, produced by “good” gut bacteria by using dietary fiber. SCFAs serve several useful purposes including nourishment for the cells that line the gut, protection of the tight junctions between those cells (prevent leaky gut), direct anti-inflammatory actions and more. Leaky gut leads to an increase in pro-inflammatory substances crossing the gut barrier and entering the body (instead of staying in the gut and leaving with stool) with a cascade of undesirable consequences. LPS (lipopolysaccharides) are bacterial wall toxins that stimulate the immune system and create inflammation. This inflammatory response is a major contributor to death in the setting of systemic infections (sepsis).

If you are interested in understanding this picture you can read the entire article here.

It is clear from this picture that the authors recommend beans and whole grains. I advise  against the consumption of grains and legumes in favor of colorful vegetables which provide for 5-7 times the amount of fiber per calorie compared to grains. Many reasons to avoid grains and legumes discussed on the website many times.

Fiber-rich diets are the main fermentable sources for SCFAs which contribute to the attenuation of systemic inflammation by inducing regulatory T cells. (Lucas et al., 2018) and through multiple other mechanisms.

SCFAs are one of many metabolites produced by gut bacteria that contribute to the prevention of depression

The mechanisms of action include direct communication to the brain through the vagus nerve, absorption of SCFAs into the blood where it can reach the brain and have beneficial effects, dampening of the inflammatory immune response, protecting the gut lining as mentioned above. These are depicted below.

 

SCFAs and depression

Image Source : Microb Cell 2019 Oct 7,; 6(10): 451-481, PMID 31646148

Exercise protects against depression and is useful as therapy for depression.

In her discussion of depression as a brain inflammatory disorder Psychiatrist Emily Dean describes well some of these interactions.

This is not the first time I have observed  very limited access to nutritious foods, exercise and sunlight in the setting of a psychiatric hospital. Unfortunately, it will likely not be the last despite multiple studies and articles in the medical literature pointing to the importance of these three ingredients for general and psychiatric health.

To prevent and treat depression and other psychiatric illnesses, nutrition, exercise, sunshine are all important. Lack of these basic treatment modalities hampers recovery and health.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose.

Doctor Bob

 

 

 

 

Chronic Pain: Opiate use can make it worse

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For several years a dysfunctional response to opiate prescription medications for chronic pain has been discussed in the medical literature. This dysfunctional response paradoxically makes pain worse! Various animal models have demonstrated “hyperalgesia” (increased pain response to a painful stimulus) in rodents given opiate medications for pain. A process called “central sensitization” occurs in which the nervous system becomes an amplifier (amplifying pain signals to the brain) rather than a muffler (inhibiting pain messages ascending the spinal cord to the brain). Many cellular mechanisms have been identified as potentially contributing to this iatrogenic situation.

A recent study has provided yet another possible contributing mechanism that involves an auto-immune response in which the opiate medication (such has hydrocodone or oxycodone found in NORCO and PERCOCET) chemically combines with a normal protein in human blood. This combination is called a hapten. Haptens have been known to cause a variety of auto-immune diseases including halothane hepatitis and a specific form of hemolytic anemia. Both can be life threatening.

You can view a brief video on the results of the research here:

View this video to understand one of many possible mechanisms causing a paradoxical response to opiate pain medications in which pain is worsened rather than improved.

You can view previous posts related to pain here

https://practical-evolutionary-health.com/2015/03/22/chronic-pain-how-does-it-occur-and-what-can-be-done-about-it/

and here:

https://practical-evolutionary-health.com/category/pain/

Opiate pain medications such as morphine and fentanyl can be profoundly beneficial in the acute settings of trauma and surgery, but chronic use is rarely justified because of side effects, tolerance and addiction. Instead, lifestyle and rehabilitation modalities should be employed. These can have significant beneficial effects in the setting of chronic pain. I presently practice interventional pain management at TPM Medical Clinic, combining allopathic techniques with lifestyle interventions to help patients get off of chronic opiate medications and improve quality of life and functional status.

http://www.tpmclinic.com/

The tpmclinic website is an award winning patient educational website that describes various techniques used to treat chronic pain.

This website is devoted to the effects of nutrition, sleep, stress reduction, exercise, sunshine, circadian rhythm and social connection on health and health-span. But all of these factors influence the experience, suffering and prognosis of chronic pain, no matter what the cause.

In the context of the COVID 19 pandemic I will close with the usual summary.

  1. Avoid alcohol consumption (alcohol wreaks havoc with your immunity)
  2. Get plenty of sleep (without adequate sleep your immune system does not work well )
  3. Follow good sleep habits
  4. Exercise, especially out of doors in a green space, supports the immune system
  5. Get some sunshine and make sure you have adequate Vitamin D levels.
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Eliminate refined-inflammatory “vegetable oils” from your diet, instead eat healthy fat.
  10. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

COVID 19 Fatality Rate vs Flu, the social media incorrect comparisons persist despite the data demonstrating a large difference.

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I have previously posted an analysis of the IFR (infection fatality rate) of COVID 19 vs influenza.

Here it is again, an excerpt from my previous post:

The infection fatality rate (IFR) for COVID-19 IS 25 times greater than the H1N1 FLU pandemic of 2009.

An analysis comparing the 2009 H1N1 influenza A pandemic to COVID 19 suggests this:

 Case Fatality RateInfection Fatality Rate
2009 H1N1 Virus (flu)0.1% to 0.2%0.02%
COVID-19 New York8%0.50%
CFR is # deaths/#cases identified by nasal PCR, IFR is # deaths/actual # cases in a given population, estimated by antibody testing of a large population

References and more discussion can be found here.

https://practical-evolutionary-health.com/2020/04/25/stanford-study-on-santa-clara-county-very-questionable-conclusions/

But since that post, more data has become available suggesting that the IFR for COVID 19 may be 50 to 100 times greater than the aggregate of multiple flu viruses experienced during the past several years.

You can find an informative discussion about this data here.

https://medium.com/@gidmk/covid-19-is-far-more-lethal-than-influenza-69b6628e69f2

A common problem has been that various bloggers, social media discussions, and news reports have compared the CFR of previous flu pandemics with the IFR of COVID 19. In fact the CDC website presents a fatality rate for the “flu” to be in the range of 0.1 to 0.2 %, and this number is widely quoted. But if you dig a little deeper you will learn that this is the CFR for the flu, not the IFR. Yet it has been directly compared to the IFR for COVID 19, which is very misleading.

What is the most recent data on COVID 19?

First a quote from the study:

Conclusion Based on a systematic review and meta-analysis of published evidence on COVID-19 until May, 2020, the IFR of the disease across populations is 0.68% (0.53-0.82%). However, due to very high heterogeneity in the meta-analysis, it is difficult to know if this represents the true point estimate. It is likely that, due to age and perhaps underlying comorbidities in the population, different places will experience different IFRs due to the disease. Given issues with mortality recording, it is also likely that this represents an underestimate of the true IFR figure.

And here is a graphic from the study showing the range of IFR in various populations:

Here is a link to the study:

https://www.medrxiv.org/content/10.1101/2020.05.03.20089854v4 A systematic review and meta-analysis of published research data on COVID-19 infection-fatality rates

Note that this is a preprint with the following caveat: This article is a preprint and has not been peer-reviewed [what does this mean?]. It reports new medical research that has yet to be evaluated and so should not be used to guide clinical practice.

I will follow this up to make sure it is published after peer review but so far the data looks reliable.

So a more thorough and updated look at COVID 19 infection fatality rate utilizing a larger data base suggests an IFR higher than the one I originally reported, based upon a NY study. (0.65% vs 0.5%, but the same ballpark)

Now for the data on the IFR for “the flu”.

Here is the link to CDC data on the flu for various years.

https://www.cdc.gov/flu/about/burden/index.html

But when you explore this data please keep in mind the difference between CFR and IFR. Because asymptomatic + subclinical flu infections can be > 50% depending on the year, when you adjust the CFR for the greater denominator (to include asymptomatic and subclinical infections) to calculate an IFR for the flu you will understand the dramatic difference, consistent with the 2009 H1N1 South Korea data presented in the table above.

http://Heterogeneous and Dynamic Prevalence of Asymptomatic Influenza Virus Infections

Abstract

Influenza infection manifests in a wide spectrum of severity, including symptomless pathogen carriers. We conducted a systematic review and meta-analysis of 55 studies to elucidate the proportional representation of these asymptomatic infected persons. We observed extensive heterogeneity among these studies. The prevalence of asymptomatic carriage (total absence of symptoms) ranged from 5.2% to 35.5% and subclinical cases (illness that did not meet the criteria for acute respiratory or influenza-like illness) from 25.4% to 61.8%. Statistical analysis showed that the heterogeneity could not be explained by the type of influenza, the laboratory tests used to detect the virus, the year of the study, or the location of the study. Projections of infection spread and strategies for disease control require that we identify the proportional representation of these insidious spreaders early on in the emergence of new influenza subtypes or strains and track how this rate evolves over time and space.

Calculate the average of asymptomatic and subclinical flu cases. They average 15.3% and 48.6% respectively. (5.2% plus 35.5% divided by 2, 25.4% plus 61.8% divided by 2 respectively). Add the two and you get an average of 63.95% of the US population being asymptomatic or subclinical cases of the flu in any given year. Yes that is high, and yes it is the best data available.

Now take a more conservative 50 % as applied in my calculation below. But first the CDC website.

If you go to the CDC website you will see a table that shows data for “symptomatic illnesses” with hospitalizations and deaths. Which means the fatality rates are CFRs not IFRs. The CFR for multiple flu seasons averages out to about 0.1%. Here is the chart.

Symptomatic IllnessesMedical VisitsHospitalizationsDeaths
SeasonEstimate95% U IEstimate95% U IEstimate95% U IEstimate95% U I
2010-201121,000,000(20,000,000 – 25,000,000)10,000,000(9,300,000 – 12,000,000)290,000(270,000 – 350,000)37,000(32,000 – 51,000)
2011-20129,300,000(8,700,000 – 12,000,000)4,300,000(4,000,000 – 5,600,000)140,000(130,000 – 190,000)12,000(11,000 – 23,000)
2012-201334,000,000(32,000,000 – 38,000,000)16,000,000(15,000,000 – 18,000,000)570,000(530,000 – 680,000)43,000(37,000 – 57,000)
2013-201430,000,000(28,000,000 – 33,000,000)13,000,000(12,000,000 – 15,000,000)350,000(320,000 – 390,000)38,000(33,000 – 50,000)
2014-201530,000,000(29,000,000 – 33,000,000)14,000,000(13,000,000 – 16,000,000)590,000(540,000 – 680,000)51,000(44,000 – 64,000)
2015-201624,000,000(20,000,000 – 33,000,000)11,000,000(9,000,000 – 15,000,000)280,000(220,000 – 480,000)23,000(17,000 – 35,000)
2016-201729,000,000(25,000,000 – 45,000,000)14,000,000(11,000,000 – 23,000,000)500,000(380,000 – 860,000)38,000(29,000 – 61,000)
Preliminary estimates*Estimate95% UIEstimate95% UIEstimate95% UIEstimate95% UI
2017-2018*45,000,000(39,000,000 – 58,000,000)21,000,000(18,000,000 – 27,000,000)810,000(620,000 – 1,400,000)61,000(46,000 – 95,000)
2018-2019*35,520,883(31,323,881 – 44,995,691)16,520,350(14,322,767 – 21,203,231)490,561(387,283 – 766,472)34,157(26,339 – 52,664)

* Estimates from the 2017-2018 and 2018-2019 seasons are preliminary and may change as data are finalized.

And here is another graphic.

“Illnesses” above include only symptomatic cases, that number does not include the much greater subclinical and completely asymptomatic cases.

Looking at the table and graphics above remember that the population of the US is 331 million. If 50% of the population has subclinical or asymptomatic flu infection that means the denominator would be 165 million plus the number of symptomatic cases. Run the math for the lowest and highest symptomatic infection years. You get an IFR range of 0.0069% to 0.0290% for the flu. The higher of these two is very close to the number in my chart above from my earlier post. Here it is again.

 Case Fatality RateInfection Fatality Rate
2009 H1N1 Virus (flu)0.1% to 0.2%0.02%
COVID-19 New York8%0.50%
CFR is # deaths/#cases identified by nasal PCR, IFR is # deaths/actual # cases in a given population, estimated by antibody testing of a large population

So the data are consistent over time.

So next time someone quotes a fatality rate of 0.1% for the flu, remember that this is the CFR (based upon symptomatic illness) not the IFR (based upon the true population prevalence which would include all infections, with symptoms, without symptoms, and subclinical infections). The CDC denominator (# cases) includes only “symptomatic illness.”

If these numbers do not convince those who claim no difference between “the flu” and COVID 19, they should also consider the following observations.

No influenza pandemic in the past several decades has ever overwhelmed the NYC hospital system and the NYC morgues as the COVID 19 pandemic has.

No influenza pandemic has required 200 refrigerated trucks sitting outside of hospitals, each filled with 100 chilled corpses per truck in a single city, with all morgues filled, on the verge of bulldozing mass graves (yes, that is what happened in NYC). NYC did not shelter in place as early as Seattle and San Francisco, NYC delayed about 11 days compared with the later two. Of course NYC has a subway system which made things worse but here is the point: never happened before with any flu in NYC.

No influenza pandemic has required a national guard unit specifically trained to handle mass casualties (dead bodies) which has been the case in NYC. Members of that national guard unit reported that they had never experienced a war zone or natural disaster that compared with COVID 19 in NYC. Remember this unit responded to hurricane Katrina and many war zones. Their sole job is to handle dead bodies. Their members experienced high rates of PTSD in NYC as did doctors and nurses in ERs and ICUs.

These events have not occurred with any previous flu pandemic. They occurred with COVID 19. Why the difference? If COVID 19 is just another flu, why have these events not occurred with previous flu seasons?

One must also consider the large number of disabled (cardiac and respiratory cripples) survivors of COVID-19, being reported on an increasing basis. These are not included in fatality rates, but represent an additional burden of COVID-19 compared to the survivors of influenza infections who have faired much better historically.

And finally consider a recent study comparing the 2019 H1N1 (“Spanish flu”) to COVID 19. The Spanish flu killed 50 million worldwide (some estimates higher). This study compared all-cause deaths in both pandemics.

You can view it here. http://Full text COVID-19 and 1918 Flu Mortality in NYC ‘In the Same Ballpark’

Deaths in New York City During the 1918 H1N1 Influenza Pandemic and the Coronavirus Disease 2019 (COVID-19) Pandemic and During the Preceding Years of Both Pandemics

Res Ipsa Loquitur.

In the context of the COVID 19 pandemic I will close with the usual summary.

  1. Avoid alcohol consumption (alcohol wreaks havoc with your immunity)
  2. Get plenty of sleep (without adequate sleep your immune system does not work well )
  3. Follow good sleep habits
  4. Exercise, especially out of doors in a green space, supports the immune system
  5. Get some sunshine and make sure you have adequate Vitamin D levels.
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Eliminate refined-inflammatory “vegetable oils” from your diet, instead eat healthy fat.
  10. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

COVID 19: Masks and Distance not enough, where we have faltered and failed

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  1. Test
  2. Trace
  3. Isolate

That is where we have failed. Those countries that rapidly instituted masks, social distance, frequent hand washing, PLUS Test/Trace/Isolate succeeded in limiting the speed of spread, protected the Medical Care (hospital) system from being over-run, and protected it’s citizens and economy. Those countries bought time to learn enough about the virus to lower the mortality rates by developing treatments that decrease risk of death AND probably disability and to ramp up the hospital care system and PPE.

The US has failed to meet the challenge.

Death may not be the worst outcome, depending on one’s views relative to the balance between longevity and quality of life. Chronic disability (such as congestive heart failure, severe pulmonary insufficiency, kidney failure requiring dialysis, stroke, etc.) can be lifelong and devastating following this infection. Some may consider that shortness of breath after walking 100 feet, requiring a rest before moving on, or kidney dialysis 3 times per week the price one must pay to survive a serious infection. Others may think this sort of severe disability is not acceptable. Many in our society are clueless about these potential outcomes (usually that means they are in denial, a very common defense mechanism used to deal with a terrible threat).

This did not have to be our present state, but it is.

In December US intelligence agencies (including the CIA) and the US military intelligence were already issuing reports about an emerging deadly respiratory virus in China. This went up the chain of command but was ignored by the Whitehouse. In January, Doctor Fauci, at the annual BIOTHREATS CONFERENCE in Washington DC, announced to the bio-tech industry representatives in attendance that this virus was already “beyond containment” and stated that aggressive biomedical development (drugs, vaccines, etc.) would be required. He told attendees that the NIH would “find the money” to support these efforts and that this was a national and global emergency.

Undoubtedly, this was reported to the Whitehouse. These early warnings were not only ignored, they were also widely denied publicly by our highest public official. (The warnings issued in senatorial and congressional committee meetings however, prompted many privileged senators and congress people to sell pandemic-sensitive stocks very early in the “denial phase”).

It is clear that masks and social distancing are effective in limiting spread. Super-spreader cases, case studies of spread in restaurants (China) , call centers (South Korea), and choir rehearsals (Washington State) suggest that both droplet and aerosol transmission occur in non-medical procedure settings.

We already knew that aerosol spread occurred in operating rooms when nasopharyngeal surgery and similar aerosol generating medical procedures were performed. In one operating room event, all 11 doctors and nurses who spent any amount of time in that operating room (despite everyone wearing N95 masks) became infected and the surgeon died from the infection (he had the most exposure). This was reported early on documenting aerosol spread in medical settings.

For those who have not read my previous discussion of aerosol vs droplet spread:

Aerosol = very small lighter-than-air particles containing infectious virus that float in the air and can be recirculated through air-conditioning vents or linger suspended in the air, especially indoors where the air is still.

Droplets = larger particles that fall quickly onto surfaces but can also with a cough, sneeze, scream or singing be transmitted to someone in very close proximity before falling .

Then we learned that carriers/transmitters of the virus can either remain completely without symptoms or develop symptoms as late as 10 days after initial exposure, all the while transmitting the virus to others around them. Assymptomatic transmission makes COVID 19 different from and more dangerous than most other viruses that infect humans.

Let me say that again.

Aerosol transmission makes this virus more dangerous than most other viruses.

Asymptomatic transmission makes this virus more dangerous than most other viruses.

And finally we have learned that this virus is more lethal than most other viruses. For example, COVID 19 is 25 times more lethal than the H1N1 influenza pandemic (references provided in previous post).

https://practical-evolutionary-health.com/2020/07/12/covid-19-update-what-have-we-learned/

To summarize, the combination of easy transmission, asymptomatic transmission, and high mortality rate make this virus exceptionally dangerous and difficult to control.

How did the US respond?

Instead of rapidly ramping up PPE, testing, tracing, and isolation public health capability we instead had national leadership that said this was just like “another flu” virus and would “go away”. The narrative constantly shifted, but more importantly, effective action was not taken, and still has not been taken.

Testing remains woefully inadequate.

In many areas of our country it can take 5 days to schedule a test and 10 days to get the results. Such tests are useless. To effectively implement TEST/TRACE/ISOLATE we need rapid and widespread testing, rapid reporting, and a system to then trace contacts and isolate infected and exposed individuals. The US still shamefully lacks these essential services.

John’s Hopkins University early on developed an on-line contact tracing training program. But public funding to hire such trained individuals has been inadequate.

Isolation requires facilities in which exposed or infected individuals have their own bathroom and bedroom, have food provided, and are medically supervised until they are no longer infectious.

The US does not have such facilities. Individuals, unless they are financially very secure, do not have access to a home or other environment where this is possible. Worse, those essential workers (meat packers, food delivery, nursing aids, etc.) who earn the least, usually live in cramped housing conditions with multi-generation households in which isolation is impossible. Such individuals often live from paycheck to paycheck, so staying home from work means the family does not eat or the rent is not paid. So they go to work infecting others.

The result has been not just death and disability but horrible economic consequences.

Our shutdowns could have been shorter had we acted quickly and effectively.

Had we responded rapidly and appropriately, we would not be in our present economic predicament. So ironically and tragically, those that complain that shutdowns “were not necessary” and masks “are not necessary” contribute to the worsening economic consequences. As the virus surges following relaxation of restrictions, further restrictions and economic consequences become necessary.

Compounding this situation is the denial on the part of many individuals regarding the science and facts about this virus. Part of this denial is the result of our con-artist in chief, (and some governors) misrepresenting the facts to the public and displaying inappropriate behavior (such as refusal to wear a mask until most recently).

The other component of this denial is based on the natural tendency of humans to ignore data that is threatening and not consistent with personal ideology and beliefs. Beliefs such as “the government lies, the government is not to be trusted, the government cannot tell me what to do” presents obstacles to social behavior that would protect not just oneself and family, but the community (and economy) in general.

Contact tracers have reported that sometimes people hang up on them, refuse to cooperate, sometimes saying that it is an “invasion of privacy” or a “government hoax”.

Such beliefs and behaviors are encouraged by misinformation in the social media, shock-jocks such as Rush Limbaugh, conspiracy theories, and supported by dangerous politicians who have placed party over country, ideology over science, the next election over the good of the country.

The best way to mitigate the dire health and ECONOMIC CONSEQUENCES of this pandemic include all those components that have worked in other countries:

  • MASKS4ALL
  • SOCIAL DISTANCE
  • FREQUENT HAND WASHING
  • SOCIAL BUBBLE

TEST/TRACE/ISOLATE

This is a sad state. In the meantime what can you do?

In the context of the COVID 19 pandemic I will close with the usual summary.

  1. Avoid alcohol consumption (alcohol wreaks havoc with your immunity)
  2. Get plenty of sleep (without adequate sleep your immune system does not work well )
  3. Follow good sleep habits
  4. Exercise, especially out of doors in a green space, supports the immune system
  5. Get some sunshine and make sure you have adequate Vitamin D levels.
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Eliminate refined-inflammatory “vegetable oils” from your diet, instead eat healthy fat.
  10. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

COVID 19: Can you get it twice?

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There have been some case reports of individuals who have developed symptomatic COVID-19, tested positive, then negative, then several weeks later positive again. Does this mean they were re-infected? Probably not (but we are not certain).

For a great, short interview on science Friday that addresses this topic listen here.

https://www.sciencefriday.com/segments/coronavirus-antibodies/

This is an interview with Columbia University Virologist Angela Rasmussen.

Quick summary:

Some studies have demonstrated that “neutralizing antibodies” initially detected in recovered COVID 19 patients can disappear (not measurable) after several weeks. But this does not mean those patients do not have immunity.

The immune response involves several cell types including B memory cells, T memory cells, and T helper cells. When a previously infected patient no longer has detectable antibodies they can still have memory cells of both types as well as T helper cells. When challenged (exposed) to the virus again those memory cells can become activated. They can then proliferate and respond to the virus. The B memory cells produce antibodies and the T memory cells become “killer cells” which can kill infected cells, stopping replication of the virus and controlling infection.

A T helper cell is a type of immune cell that stimulates killer T cells, macrophages, and B cells to make immune responses. A helper T cell is a type of white blood cell and a type of lymphocyte. Also called CD4-positive T lymphocyte.

A study in South Korea looked at 300 patients who were infected, cleared the virus (symptoms resolved and PCR test turned negative) but then subsequently tested positive again (nasal PCR). All of the contacts for these patients were traced and there was no evidence of virus transmission from any of the 300 patients, suggesting that the positive PCR nasal swab represented non-infectious residual virus remnant particles. In addition, cell culture tests in all of these patients was negative for infectious virus, further pointing to false positive repeat tests in all 300 patients.

One study found that some patients with no symptoms of Covid-19 had T-cells that recognized the virus — even when they had no detectable antibodies. 

ABSTRACT

SARS-CoV-2-specific memory T cells will likely prove critical for long-term immune protection against COVID-19. We systematically mapped the functional and phenotypic landscape of SARS-CoV-2-specific T cell responses in a large cohort of unexposed individuals as well as exposed family members and individuals with acute or convalescent COVID-19. Acute phase SARS-CoV-2-specific T cells displayed a highly activated cytotoxic phenotype that correlated with various clinical markers of disease severity, whereas convalescent phase SARS-CoV-2-specific T cells were polyfunctional and displayed a stem-like memory phenotype. Importantly, SARS-CoV-2-specific T cells were detectable in antibody-seronegative family members and individuals with a history of asymptomatic or mild COVID-19. Our collective dataset shows that SARS-CoV-2 elicits robust memory T cell responses akin to those observed in the context of successful vaccines, suggesting that natural exposure or infection may prevent recurrent episodes of severe COVID-19 also in seronegative individuals.

The last sentence is good news, supporting immunity after infection or exposure with COVID-19 specific memory T cells in the absence of measurable antibodies. Future studies will tell us more about whether the presence of these T cells can prevent re-infection or at least limit the degree of illness.

There is also the possibility that there is some cross reactivity between one of the four common cold Corona viruses and the COVID 19 virus, as suggested by the low incidence of COVID 19 infection on an Island off the coast of Tuscany despite infected travelers from the mainland bringing the virus across to the island. The previous year the island had experienced a particularly bad bout of the common cold.

Another study of COVID-19 specific T cells in Sweden has recently supported sustained memory T cells in previously infected patients and their contacts in the absence of antibodies . It also demonstrated antibodies against COVID 19 in unexposed individuals suggesting cross reactive antibodies from previous infection with other corona viruses.

Targets of T Cell Responses to SARS-CoV-2 Coronavirus in Humans with COVID-19 Disease and Unexposed Individuals

https://www.sciencedirect.com/science/article/pii/S0092867420306103?via%3Dihub

“Using HLA class I and II predicted peptide “megapools,” circulating SARS-CoV-2-specific CD8+ and CD4+ T cells were identified in ∼70% and 100% of COVID-19 convalescent patients, respectively. CD4+ T cell responses to spike, the main target of most vaccine efforts, were robust and correlated with the magnitude of the anti-SARS-CoV-2 IgG and IgA titers. The M, spike, and N proteins each accounted for 11%–27% of the total CD4+ response, with additional responses commonly targeting nsp3, nsp4, ORF3a, and ORF8, among others. For CD8+ T cells, spike and M were recognized, with at least eight SARS-CoV-2 ORFs targeted. Importantly, we detected SARS-CoV-2-reactive CD4+ T cells in ∼40%–60% of unexposed individuals, suggesting cross-reactive T cell recognition between circulating “common cold” coronaviruses and SARS-CoV-2.”

There is much more to learn about this novel virus. Because of it’s high lethal rate (25 times greater than the previous H1N1 flu virus pandemic) and it’s greater transmission capability (from asymptomatic as well as symptomatic patients, both droplet and aerosol transmission) intensive and unprecedented research efforts are being made.

There are 100 different vaccines under early study. Two vaccines (Oxford University and Moderna) have completed phase 1/2 and phase 1 studies respectively, demonstrating safety and anti-body responses. Phase 3 studies will determine whether and how effective they might be and provide more data on safety.

In the context of the COVID 19 pandemic I will close with the usual summary.

  1. Avoid alcohol consumption (alcohol wreaks havoc with your immunity)
  2. Get plenty of sleep (without adequate sleep your immune system does not work well )
  3. Follow good sleep habits
  4. Exercise, especially out of doors in a green space, supports the immune system
  5. Get some sunshine and make sure you have adequate Vitamin D levels.
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Eliminate refined-inflammatory “vegetable oils” from your diet, instead eat healthy fat.
  10. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

Three Major Threats to Global Health

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Our world faces three major threats.

  1. Global Warming
  2. Daily loss of nutrient rich top soil with desertification of arable land
  3. COVID-19 pandemic

The first two threats are intimately related to each other. As the climate and our oceans warm and seas rise, the ecologic and economic consequences will be profound. Species are threatened and become extinct, biodiversity which sustains the global ecology and global economy diminishes on a daily basis. Loss of trees and native plants accelerates global warming. Melting of the polar ice caps and mountain glaciers results in less reflectance of solar energy back into space and more absorption of solar energy by the planet, producing a positive feedback loop that is cooking our planet.

Warming climate combined with loss of habitat (especially loss of rainforests) has produced a non-sustainable advance that has already caused tens of thousands of insect species to become extinct. Loss of insects, at the base of the food chain, and loss of essential microbes in our soil, threaten all species on earth, including humans.

Mono-agriculture has produced quantitative and qualitative loss of topsoil and arable land. Soil is a living organism. Arable land requires not just nutrient rich topsoil but also a diverse abundance of microorganisms that support agriculture, native plants, and the entire food chain. Ditto the effects on the health of our oceans, seas, rivers, streams and lakes.

There has been a pseudo-scientific movement away from raising animals as a food source. We have been told that only a vegetarian or vegan diet can sustain the planet. Nothing can be further from the truth!

Creation rather than destruction of arable land requires animal waste. Feeding the world with health-supporting food will require animal and plant foods. Sustainable agriculture requires animals and their poop.

To be blunt, the future of the world’s food supply and arable fertile land depends upon the poop of wild and domestic animals, the elimination of Monoagriculture, GMOs, Roundup-ready crops, and deforestation as well as addressing the threat of global warming.

How many news headlines, films, books and friends of yours say that beef is the unhealthiest and environmentally destructive foods you could be eating? Have you cut down on your meat consumption or feel frustrated about the vilification of meat, something humans have eaten for millions of years?

The most pivotal food and environment book of 2020 is coming soon!

My friends Diana Rodgers and Robb Wolf have been trying to get the word out for years about the importance of sustainability when it comes to diet, and have just finished a new book (due out July 14) and documentary film (slated for Fall release) that addresses this complex, yet critically important topic.

What is Sacred Cow? 

Beef is framed as the most environmentally destructive and least healthy of foods, but while many argue that greatly reducing, or even eliminating it from our diets, Sacred Cow takes a more critical look at the assumptions and misinformation presented about meat – and has the science to back it up!

Where can you get it? 

Sacred Cow is available now for pre-order everywhere books are sold. They’re also offering over $200 in pre-order incentives, including a free sneak peek preview link to the film Sacred Cow! Click here for more info.

After spending years analyzing the science, the book presents a solid case that: 

  • Meat and animal fat are essential for our bodies 
  • A sustainable food system cannot exist without animals 
  • A vegan diet may destroy more life than sustainable cattle farming 
  • Regenerative cattle ranching is one of our best tools at mitigating climate change 

Sacred Cow proposes a new way to look at sustainable diets. The book takes a deep dive into the nutritional claims against meat, why cattle raised well are actually good for the environment, and address the ethical considerations surrounding killing animals for food. The truth is, you cannot have life without death, and eliminating animals from our food system could cause more harm than good.  

But even if this way of raising animals is better than our current system, surely you can’t feed the world this way, right? Yep, they tackle that too!

Order it today and get all of your questions about the impacts of eating and raising meat answered in one place.   

Have a great week! 

PS – Don’t forget to order Sacred Cow today to take advantage of their valuable pre-order incentives and the preview link to the film. Receipts must be submitted to sacredcow.info/book by July 14th!

In the context of the COVID 19 pandemic I will close with the usual summary.

  1. Avoid alcohol consumption (alcohol wreaks havoc with your immunity)
  2. Get plenty of sleep (without adequate sleep your immune system does not work well )
  3. Follow good sleep habits
  4. Exercise, especially out of doors in a green space, supports the immune system
  5. Get some sunshine and make sure you have adequate Vitamin D levels.
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Eliminate refined-inflammatory “vegetable oils” from your diet, instead eat healthy fat.
  10. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

COVID 19 UPDATE: What have we learned?

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I was recently interviewed by a health blogger, Dmitri Konash, with specific questions about COVID 19. The podcast link is below.

Here are the questions and answer notes from the podcast.

QUESTION #1: It has been almost 4 months since Covid19 was declared a global pandemic. What are the main things which we have learned about the virus over these 4 months?

Very contagious, spread by droplet AND aerosol as well as fomites (CLOTHING, surfaces, pillows, blankets, etc). Aerosols are tiny particles suspended in the air for hours following a sneeze or cough or possibly yelling or singing. Droplets are larger particles that fall to the ground or onto surfaces. Depending on the surface the virus can remain infectious for up to 72 hours following droplet spread.

Individuals without symptoms can transmit disease (unlike most viruses) so this in combination with degree of contagion is very dangerous.

The average time from exposure to develop symptoms is 5 DAYS, 97.5% of people who develop symptoms do so within 11.5 days.

Some individuals never develop symptoms but can transmit disease for 2 or more weeks.

Infected individuals can carry the virus for up to 36 days (but we do not know how long an individual can transmit the disease) Average time to clear the virus is 14 days. (nasal PCR test)

Cough and sneeze can project 26 feet through the air, that is why masks can decrease risk but decreasing projection distance and viral load.

Masks Work, they decrease risk of disease transmission and probably decrease viral load, so if transmitted the recipient is probably less likely to develop severe complications (not proven but likely true).

Most infections are transmitted in closed spaces where many people are congregated and socializing such as parties, social gatherings, meetings, bars and restaurants.

Outdoor activity is safer.

The longer the contact between individuals the greater the risk.

The closer the contact the greater the risk.

Anyone can die from the virus but risk increases with age, diabetes, pre-diabetes, obesity, heart and lung disease, immune-compromise.

Any organ can be affected, lungs, brain, heart, kidneys, blood vessels.

Hyper-coaguable state can cause blood clots in the legs, lungs, heart and brain, any organ.

After recovering from infection individuals can suffer permanent damage to these organs.

We do not know how many people who recover will be immune or how long immunity could last. Already one case of re-infection has been reported.

The infection fatality rate (IFR) for COVID-19 IS 25 times greater than the H1N1 FLU pandemic.

A recent analysis comparing the 2009 H1N1 influenza A pandemic to COVID 19 suggested this:

 Case Fatality RateInfection Fatality Rate
2009 H1N1 Virus (flu)0.1% to 0.2%0.02%
COVID-19 New York8%0.50%
CFR is # deaths/#cases identified by nasal PCR, IFR is # deaths/actual # cases in a given population, estimated by antibody testing of a large population

For a discussion on the difference between CFR (case fatality rate) and IFR (infection fatality rate) see my previous post.

https://practical-evolutionary-health.com/2020/04/25/stanford-study-on-santa-clara-county-very-questionable-conclusions/

QUESTION #2: We reached the new high of newly diagnosed cases on June 28th. It looks like the virus is not subsiding. What is the status re drug and vaccine development?

Vaccine will likely take at least a year to develop, test, then manufacture and distribute.

Initially most vulnerable will probably take priority for vaccination. Massive vaccination will take longer.

THERE HAS NEVER BEEN A SUCCESSFUL CORONA VIRUS Vaccine. There are many corona viruses. They mutate quickly and a vaccine that works initially may become ineffective if/when new strains emerge.

Decadron (dexamethasone) IV decreases mortality rates in very sick patients.

Remdesivir shortens illness and might decrease mortality rate (the reduction compared to placebo fell short of statistical significance, p=0.059, cut-off for statistical significance is usually P=0.050)

Hydroxychloroquine and chloroquine have failed to show any benefit. A prevention trial remains underway.

There is no “cure”, just risk reduction.

QUESTION #3: What are the latest recommendations on prevention?

Social distance

Mask

Frequent hand washing

Get adequate sleep, sleep deprivation impairs immunity

Avoid alcohol which suppresses the immune system.

Get sunshine (vitamin D)

Develop a social “bubble”, limit contacts to close, reliable (responsible behavior) individuals

Exercise out of doors.

If overweight or obese, LOSE WEIGHT (Low Carb High Fat diet is MOST EFFECTIVE in combination with time restricted eating)

IF diabetes or pre-diabetes, carbohydrate restriction can rapidly achieve better blood sugar control, which is linked to risk reduction. Regular exercise can also improve insulin sensitivity, as can improved sleep habits.

QUESTION #4: There was some information recently about potential long-term impact on vital body organs for patients who had only mild symptoms. What actions do people who were tested positive for COVID19 should take to minimize long term impact to their health?

Follow general principles of healthy living (visit my website)

Sleep

Nutrition-anti-inflammatory diet

Exercise

Sunshine

Stress reduction

Social-community support

Minimize environmental toxin exposure (organic foods, safe personal and home-care products, visit EWG.org)

QUESTION #5: What actions should be taken by people who have been tested negative for COVID19 ? 

Same answer as question #4 above, lifestyle changes to enhance immune function and reduce systemic inflammation.

On July 10, a review article on COVID 19 was published in JAMA.

Pathophysiology, Transmission, Diagnosis, and Treatment
of Coronavirus Disease 2019 (COVID-19)

Here is the link.

https://jamanetwork.com/journals/jama/fullarticle/2768391

The case-fatality rate for COVID-19 varies markedly by age, ranging from 0.3 deaths per 1000 cases among patients aged 5 to 17 years to 304.9 deaths per 1000 cases among patients aged 85 years or older in the US. Among patients hospitalized in the intensive care unit, the case fatality is up to 40%

And here is a link to the JAMA patient information page for COVID 19.

https://jamanetwork.com/journals/jama/fullarticle/2768390

In the context of the COVID 19 pandemic I will close with the usual summary.

  1. Avoid alcohol consumption (alcohol wreaks havoc with your immunity)
  2. Get plenty of sleep (without adequate sleep your immune system does not work well )
  3. Follow good sleep habits
  4. Exercise, especially out of doors in a green space, supports the immune system
  5. Get some sunshine and make sure you have adequate Vitamin D levels.
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Eliminate refined-inflammatory “vegetable oils” from your diet, instead eat healthy fat.
  10. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

Fat Fiction: this movie could save your life

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The USDA Dietary Guidelines are about to be published again with an update. Unfortunately, despite much input from the scientific community requesting that the dietary guidelines address the epidemics of obesity and diabetes, it looks like nothing will change. More than 50 scientific papers that support a Very Low Carbohydrate approach to address obesity, diabetes and pre-diabetes will be ignored.

But if you want a more scientific perspective I suggest you watch this movie. You can watch it free on Amazon Prime.

If you have read Good Calories Bad Calories by Gary Taubes or Big Fat Surprise by Nina Teicholtz. then you have already been exposed to the sad history of dietary recommendations in the United States and the tragic results.

Both books are well researched and present accurate science. The movie Fat Fiction reviews the sad history of dietary advice in the US. It presents many examples of patients whose lives were changed and improved by following the advice of nutritionists and physicians who have instead, followed the science and abandoned the ideological-unscientific USDA dietary guidelines.

The American Diabetes Association has finally recognized a VLC ketogenic diet as a valid approach to treating type 2 diabetes. In fact, a ketogenic diet is the only diet that has ever been documented in controlled clinical trials to reverse diabetes type 2 and get patients off insulin and oral medications used to treat diabetes.

Unfortunately, the USDA guidelines and the American Heart Association recommendations continue to recommend unhealthy inflammatory refined “vegetable oils” (processed/refined oils from corn, soy, safflower, peanuts, cottonseed, etc.) and high carbohydrate/low fat meals. The high carb/low fat approach to cardiovascular disease, obesity, and diabetes has been an absolute failure, increasing rather than decreasing the risk of heart attack and stroke as well as contributing to the explosive epidemics of obesity and DM2. The low fat dogma has fostered the obesity and diabetes epidemics since this dogma was first introduced in the mid 20th century. The low-fat ideology remains fully supported by financial contributions from the processed-food industry, creating a financial conflict of interest for the AHA and similar organizations.

In the context of the COVID 19 pandemic, where obesity, insulin resistance, pre-diabetes and diabetes type II are major risk factors for death from the infection, it is even more imperative that individuals suffering from these risk factors stop using medications to treat problems created by food and instead clean up their diet.

“You can’t throw drugs at a nutritional disease and expect it to work” (Dr. Sarah Hallberg, TEDtalk)

You can fight systemic inflammation with the anti-inflammatory diet I present on this website, but if you have obesity, diabetes or pre-diabetes, the very low-carb version is the most effective and sustainable nutritional approach. Full fat dairy is optional (although technically not part of our evolutionary nutrition) and if you are obese, overweight, diabetic or pre-diabetic and full fat dairy is necessary for you to achieve a ketogenic diet, then go for it. But make sure you include an abundance of non-starchy vegetables which are an important component of a healthy ketogenic diet.

In the context of our present pandemic I will repeatedly say:

  1. Avoid alcohol consumption (alcohol wreaks havoc with your immunity)
  2. Get plenty of sleep (without adequate sleep your immune system does not work well )
  3. Follow good sleep habits
  4. Exercise, especially out of doors in a green space, supports the immune system
  5. Get some sunshine and make sure you have adequate Vitamin D levels.
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Eliminate refined-inflammatory vegetable oils from your diet, instead eat healthy fat.
  10. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

Chronic Inflammation, the silent killer

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I was recently interviewed by a health blogger for his podcast. The topic was chronic inflammation. Here it is.

I prepared some notes for the interview. Here are the questions and answers.

What made you so interested in the topic of chronic inflammation?

Interest in chronic inflammation:

  • Emerging evidence, source of most chronic disease including mental health (depression, etc.) is inflammation
  • family health issues experience personally
  • health care policy interest since graduate school
  •  First started to question USDA dietary advice after reading GOOD CALORIES, BAD CALORIES, by Gary Taubes,
  • Experienced Statin myopathy, researched statin drugs, bad data, financial conflicts of interest. Sought alternative approaches to Coronary Artery Disease prevention.
  • In USA, Profit driven health care system evolved from more benign not-for-profit earlier system in medical insurance and hospital system. Drug and surgery oriented. Corporate ownership of multiple hospitals, concentration of wealth and power in the industry and in society in general
  • Saw this every day: growing obesity, Metabolic Syndrome, DMII, auto-immune disease. Root causes NOT ADDRESSED.
  • While recovering from surgery attended on line functional medicine conference on auto-immune disease, covering diet, sleep, exercise, sunshine, Vitamin D, environmental toxins, gut dysbiosis, intestinal permeability (THE GATEWAY TO AUTOIMMUNITY IS THROUGH THE GUT).
  • Introduced to EVOLUTIONARY BIOLOGY and Paleo Diet by my son

What diseases does chronic inflammation typically lead to? 

  • Cancer
  • Diabetes
  • Obesity epidemic, DIABESITY
  • Hypertension
  • Metabolic Syndrome (3/5: HTN, insulin resistance/high blood sugar, abdominal obesity, high TGs, low HDL),
  • Autoimmune diseases
  • Degenerative arthritis
  • Neurodegenerative disorders (dementia, Parkinson’s, neuropathy, multiple sclerosis)
  • Works of Dale Bredesen (dementia, “The End of Alzheimer’s”), Ron Perlmutter (Grain Brain), Terry Wahls (The Wahls protocol for MS), all FUNCTIONAL MEDICINE looking at root cause of illness, common-overlapping threads.
  • Interplay between sleep, circadian rhythm, exercise, sunlight, stress, environmental toxins, diet, processed foods, nutritional deficiency, gut microbiome, endocrine disruptors, intestinal permeability, oral and skin microbiome, social disruptors, GUT BRAIN AXIS. These are all part of one large ECOSYSTEM.
  • Positive and negative feedback systems requiring a SYSTEMS ENGINEERING approach to understanding root causes.
  • Butyrate is the preferred substrate for colonocytes, providing 60-70% of the energy requirements for colonic epithelial cells1,2. Butyrate suppresses colonic inflammation,3 is immunoregulatory in the gut,4 and improves gut barrier permeability by accelerating assembly of tight junction proteins.5,6
  • Improves insulin sensitivity, increase energy expenditure, reduce adiposity, increases satiety hormones,
  • HDAC activity inhibitor, PROTECTS GENES from removal of necessary acetyl groups.
  • Butyrate also influences the mucus layer. A healthy colonic epithelium is coated in a double layer of mucus. The thick, inner layer is dense and largely devoid of microbes, protecting the epithelium from contact with commensals and pathogens alike. The loose, outer layer of mucus is home to many bacteria, some of which feed on the glycoproteins of the outer mucus layer itself. Both of these mucus layers are organized by the MUC2 mucin protein, which is secreted by goblet cells in the epithelium. Supplementation of physiological concentrations of butyrate has been shown to increase MUC2 gene expression and MUC2 secretion in a human goblet cell line.7,8

What are the population groups which have higher risk of chronic inflammation? 

  • Obese
  • Sedentary
  • Poor-urban-polluted environment dwelling (air, water, noise, crowding, violence, racism, oppression)
  • Divergence from ancestral evolutionary biology
  • Working environment: indoors, polluted, oppressive supervisors, no sunlight, noise pollution, air pollution, toxic social situations, repetitive motion, bad ergonomics,
  • night shift, disruption of circadian rhythm
  • both parents working, no time for real food and family interaction, supervision of children.
  • screen time- sedentary behavior, lack of outdoor activity
  • Stress of social inequality, food insecurity, violent neighborhoods, nutritional deserts

What are the “danger signs” or typical symptoms which may signal a chronic inflammation? 

DANGER SIGNS:

  • Waistline (waist to height ratio, BMI)
  • Sarcopenia (muscle as an endocrine organ)
  • Sleep disturbance
  • Pain
  • Headaches
  • Depression
  • Lack of joy.
  • Brain fog, fatigue

What are the typical biomarkers of chronic inflammation?

  • METABOLIC SYNDROME (3 or more of the following: high blood pressure, elevated blood sugar, elevated Triglycerides, low HDL, obesity)
  • CRP predictive of cardiovascular events,
  • ESR associated with arthritis
  • Stress hormones (morning cortisol levels)
  • Resting Heart Rate and Heart Rate Variability

What are the typical sources of systemic chronic inflammation?

Sources of Chronic Inflammation:

Diet

  • N6/N3 FA ratio determined by too much Refined Easily Oxidized Vegetable Oils, not enough marine sources of N3 FA,  grain fed vs grass fed/finished ruminant meat. Loren Cordain research wild game FA composition = grass fed. Margarine vs Butter. Fried foods using Vegetable oils. Oxidized fats/oils, oxy-sterols in diet.
  • Sugar excess leading to insulin resistance
  • Refined carbs leading to insulin resistance (dense acellular….)
  • Disturbance of gut  microbiome from poor nutrition (sugar, refined carbs and vegetable oils all disrupt the microbiome)
  • Gut brain axis.
  • Food ADDITIVES AND PRESERVATIVES
  • Trans Fats (finally banned)

Endocrine disruptors/ BIOACCUMULATION

  • Plastics (microparticles in our fish, food and bottled water)
  • Plastic breakdown products
  • Phthalates added to plastics to increase flexibility ( also pill coatings, binders, dispersants, film formers, personal care products, perfumes, detergents, surfactants, packaging, children’s toys, shower curtains, floor tiles, vinyl upholstery, it is everywhere) 8.4 million tons of plasticizers produced annually. EWG.org
  • Pesticides, herbicides, glyphosate (Monsanto), DIRTY DOZEN, CLEAN FIFTEEN EWG.org
  • Medications
  • ABSORBED skin, eat, drink, breath,
  • BPS is as bad as the BPA it replaced
  • Polychlorinated biphenyls used in INDUSTRIAL COOLANTS AND LUBRICANTS
  • Flame retardants (PBDEs, polybrominated dipheyl ethers) are ubiquitous in furniture and children’s clothing. Also linked to autoimmune disease
  • Dioxins
  • PAHs (polycyclic aromatic hydrocarbons
  • Sunblock
  • CUMULATIVE BURDEN, INTERACTIONS, SYNERGY?

SLEEP DEPRIVATION CHRONIC IN OUR SOCIETY

Eating late vs time restricted eating

Gut Microbiome disrupted by

  • 1/3 of prescribed medications disrupt the microbiome AND increase intestinal permeability
  • Stress
  • Sleep deprivation
  • Sugar
  • Refined carbs
  • Refined veg oils
  • Over exercise and Under exercise, both are bad.
  • Environmental toxins

Gut dysbiosis and infections include (often chronic, low grade, not diagnosed)

  • Pathogenic bacteria, infection or overgrowth/imbalance
  • SIBO
  • Parasites
  • Viruses
  • BAD bugs > good bugs
  • Good bugs make vitamins and SCFAs required for colonocyte energy
  • Gut-Brain axis huge topic, VAGUS NERVE COMMUNICATION both ways, SCFA in gut and in CIRCULATION (butyrate, propionate, acetate), NEUROTRANSMITTER PRODUCTION (SEROTONIN, OTHERS), enterochromaffin cells producing > 30 peptides.
  • Overuse of antibiotics in medicine
  • AND use of antibiotics in raising our food.
  • Vaginal delivery vs C-section
  • Breast feeding vs bottle feeding

INCREASED INTESTINAL PERMEABILITY:

  • Caused by all factors above
  • Leads to higher levels of circulating LPS-endotoxin, bacterial products that create an immune-inflammatory response.
  • Incompletely digested proteins with AA sequences overlapping our own tissue causing autoimmunity/inflammation through molecular mimicry

Heavy Metal toxicity

  • Lead
  • Mercury
  • Cadmium
  • Arsenic

MOLD TOXICITY (> 400 identified mycotoxins, can cause dementia, asthma, allergies, auto-immunity)

  • At home
  • At work

What are the most efficient natural (non-medication) ways to address chronic inflammation?

  • Anti-inflammatory Diet, real whole food that our ancestors ate through evolutionary history (grass fed/finished ruminant meat, free range poultry, antibiotic free, and pesticide free food, wild seafood (low mercury varieties), organic vegetables and fruit, nuts, fermented foods, eggs)
  • Low mercury fish and seafood for omega three fatty acids
  • Sleep hygiene
  • Exercise, not too much, not too little, rest days, out of doors, resistance training, walking, yoga, Pilates, tai chi, chi gong, dancing, PLAYING!!!!!!!!!!!!!
  • Stress reduction: meditation, mindful living, forest bathing, sunlight, Playing, music, praying, SOCIAL CONNECTION, laughter, comedy, quit the toxic job, quit the toxic relationship, SAUNA/SWEAT, heat shock proteins, exercise
  • Vitamin D, sunshine, check levels
  • PLAY, PLAY, PLAY, LAUGH, DANCE, ENJOY, LOVE
  • Be aware of potential dangers of EMF, WiFi, hand held devices, blue tooth headphones.
  • Address environmental justice
  • Address social inequality, food insecurity
  • Tobacco addiction
  • Ethanol
  • Other substance abuse
  • Agricultural subsidies in US distort the food supply
  • Loss of soil threatens food supply
  • Suppression of science (global warming, environment, etc.,) worsens environmental degradation, creating an EXISTENTIAL THREAT.
  1. Avoid alcohol consumption (alcohol wreaks havoc with your immunity)
  2. Get plenty of sleep (without adequate sleep your immune system does not work well )
  3. Follow good sleep habits
  4. Exercise, especially out of doors in a green space, supports the immune system
  5. Get some sunshine and make sure you have adequate Vitamin D levels.
  6. Eat an anti-inflammatory diet rich in micronutrients.
  7. Practice stress reduction like meditation and yoga which improves the immune system
  8. Eliminate sugar-added foods and beverages from your diet. These increase inflammation, cause metabolic dysfunction, and suppress immunity.
  9. Clean up your home environment and minimize your family’s exposure to environmental toxins by following recommendations at EWG.org with regards to household products, personal care products, and organic foods. (https://www.ewg.org/)

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

USDA Dietary Guidelines Flawed

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The NUTRITION COALITION is a non-profit organization dedicated to bringing science to dietary recommendations in the US. The COALITION recently called upon the USDA to hold off on publishing it’s updated Dietary Guidelines for US Citizens because of reported improprieties in the process of scientific review.

https://www.nutritioncoalition.us/news/usda-members-blow-whistle-flaws-in-process

The guidelines since their inception have been biased and flawed, ignoring much of the dissenting scientific opinion in testimony before the committee and cherry picking studies without a balanced approach to the scientific literature.

The confluence of the Covid-19 pandemic with the epidemics of obesity and diabetes in the US have created a perfect public health storm, as discussed in my last post. The USDA Dietary Guidelines Committee chose to ignore more than 50 studies that confirm the benefits of a Very Low Carbohydrate nutritional approach to address obesity and diabetes.

Because of the importance of the guidelines influencing US dietary choices in the context of COVID-19 I have copied the informative letter from the NUTRITION COALITION below. There is a link in the letter that will allow you to send emails to your senators, congressman, and the Secretary of Agriculture, supporting the recommendations of the NUTRITION COALITION.

Here is the letter.

Dear Friends and Colleagues, 

In a remarkable development, one or more member(s) of the Dietary Guidelines Advisory Committee recently came forth and blew the whistle, identifying serious flaws in the Dietary Guidelines process. I write to you today to ask that you contribute your voice to our effort to have these allegations taken seriously by the U.S. Departments of Agriculture and Health and Human Services (USDA-HHS). We are specifically asking these federal agencies to delay the Committee’s report, which is due out in just a matter of weeks, until the allegations can be investigated and addressed.  

The Dietary Guidelines are considered the “gold standard” of science and are a powerful lever on government feeding programs, military rations, professional medical associations, and much more—including nutrition guidelines around the world. It is imperative that they be based on good science.  

However, the current 2020 process is clearly flawed. We know, for instance, that almost all studies on weight loss have been excluded from consideration. We also know that virtually all studies on carbohydrate restriction have been excluded. Some USDA reviews of the science include the science only up to 2016, despite a Congressional mandate that the Dietary Guidelines include a comprehensive review of the science “that is current at the time.” It’s clear that the expert committee, in addition to excluding crucial science, has not been given enough time to do its work and has, essentially, had to cut corners.  

Moreover, the Advisory Committee, in its draft conclusions, indicated that the cap on saturated fats is likely to stay firmly in place. The evidence linking saturated fats to heart disease was judged to be “strong,” not only for adults, but also, for the first time, children. Yet scientific justification for a continuation of these caps is lacking, and the Subcommittee presented weak evidence to make its case. The past decade has seen a thorough reconsideration of saturated fats, and now, there are close to 20 review papers reexamining the evidence—which have near-universally concluded that saturated fats have no effect on cardiovascular or total mortality.  

Delaying the report will give time for a thorough investigation into these allegations. 

By signing this letter, you are helping to push for Dietary Guidelines that are based on a comprehensive review of the science and are therefore more likely to help the public regain its health. Thank you for any contribution to this effort!  

Click here to sign a physicians’ letter of support. In addition, it would be extremely helpful if you could also take time here to contact your representatives in Congress and let them know the importance of getting the Guidelines right. As an expert in the field, your voice will be able to resonate more than most, I hope you will take some time to try to help generate change to our far-reaching nutrition policy. 

Thank you,  

Nina Teicholz 

Executive Director 

The Nutrition Coalition  

Read more about the allegations in our press release and letter to USDA-HHS. 

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Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob