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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

 

 

 

 

Long Haulers, Brain Fog and Post Exertional Malaise

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An excellent article recently published in the Atlantic was so well written that I have cut and pasted important snippets to help create this post. The review confirms many findings uncovered in my reading of several scientific publications.

You can read the full article here:

The crushing fog of long COVID

20 to 30 percent of patients report brain fog three months after their initial infection, as do 65 to 85 percent of the long-haulers who stay sick for much longer.

Of long COVID’s many possible symptoms, brain fog “is by far one of the most disabling and destructive,”

It is more profound than the clouded thinking that accompanies hangovers, stress, or fatigue.

It is not a mood disorder.

It is almost always a disorder of “executive function”—the set of mental abilities that includes:

  1. focusing attention,
  2. holding information in mind, and
  3. blocking out distractions.

Patients state they often lose focus mid-sentence.

Difficulty with simple tasks impairs activities of daily living.

“I couldn’t unload a dishwasher, because identifying an object, remembering where it should go, and putting it there was too complicated.”

The memories are there, but with impaired executive function, the brain neither chooses the important things to store nor retrieves that information efficiently.

Most people with brain fog are not so severely affected, and gradually improve with time. But even when people recover enough to work, they can struggle with minds that are less nimble than before.

“I’ve had surgeons who can’t go back to surgery, because they need their executive function,” Monica Verduzco-Gutierrez, a rehabilitation specialist at UT Health San Antonio.

That specific constellation of problems also befalls many people living with HIV, epileptics after seizures, cancer patients experiencing so-called chemo brain, and people with several complex chronic illnesses such as fibromyalgia.

It’s part of the diagnostic criteria for myalgic encephalomyelitis, also known as chronic fatigue syndrome, or ME/CFS

People with brain fog also excel at hiding it: to protect their jobs when still able to work, or to protect their reputation, or out of embarrassment.

“I know my value in many people’s eyes will be diminished by knowing that I have these cognitive challenges.”

Individuals with previously above average cognitive ability often test “normal” but suffer significant loss compared to their prior ability.

A team of British researchers analyzed data from the UK Biobank study. The findings revealed structural changes in the brain with loss of tissue on MRI scans that correlates with symptoms.

They found that even mild infections can slightly shrink the brain and reduce the thickness of its neuron-rich gray matter. At their worst, these changes were comparable to a decade of aging.

They were especially pronounced in areas such as the parahippocampal gyrus, which is important for encoding and retrieving memories, and the orbitofrontal cortex, which is important for executive function.

In most cases the virus probably harms the brain without directly infecting it.

Inflammatory chemicals can travel from the lungs to the brain, where they disrupt cells called microglia (immune cells in the brain).

In their presence, the hippocampus—a region crucial for memory—produces fewer fresh neurons, while many existing neurons lose their insulating coats (demyelination), so electric signals now course along these cells more slowly.

These are the same changes seen in cancer patients with “chemo fog”.

Neuro-inflammation is “probably the most common way” that COVID results in brain fog, but that there are likely many such routes, such as reactivation of dormant viruses such as Epstein-Barr virus, which has been linked to conditions including ME/CFS and multiple sclerosis.

By damaging blood vessels and filling them with small clots, COVID also throttles the brain’s blood supply, depriving this most energetically demanding of organs of oxygen and fuel.

These problems can be exacerbated or mitigated by factors such as sleep and rest, which explains why many people with brain fog have good days and bad days.

Although other respiratory viruses can wreak inflammatory havoc on the brain, SARS-CoV-2 does so more potently than influenza.

For adults following SARS CoV-2 infection:

risks of cognitive deficit (known as brain fog), dementia, psychotic disorders, and epilepsy or seizures were still increased at the end of the 2-year follow-up period.

For children following SARS CoV-2 infection:

in the 6 months after SARS-CoV-2 infection, children were not at an increased risk of mood (HR 1·02 [95% CI 0·94–1·10) or anxiety (1·00 [0·94–1·06]) disorders, but did have an increased risk of cognitive deficit, insomnia, intracranial haemorrhage, ischaemic stroke, nerve, nerve root, and plexus disorders, psychotic disorders, and epilepsy or seizures (HRs ranging from 1·20 [1·09–1·33] to 2·16 [1·46–3·19])….  Unlike adults, cognitive deficit in children had a finite risk horizon (75 days) and a finite time to equal incidence (491 days).

The fact that neurological and psychiatric outcomes were similar during the delta and omicron waves indicates that the burden on the health-care system might continue even with variants that are less severe in other respects.

There are no proven drug treatments for long-haulers.

But there is hope.

Cancer researchers have developed drugs that can calm inflamed microglia in mice and restore their cognitive abilities;

“Metformin can promote the regeneration of neural precursor cell populations and improve cognitive function in a preclinical model of cranial radiation and a pilot clinical study of children after cranial radiation and chemotherapy.”

Treating cancer therapy–related cognitive impairment | Nature Medicine

With regard to long-haulers, better sleep, healthy eating, and other generic lifestyle changes can make the condition more tolerable. Breathing and relaxation techniques can help people through bad flare-ups; speech therapy can help those with problems finding words.

“Some people spontaneously recover back to baseline,”

The largest group of long-haulers—those whose brain fog has improved but not vanished, can “maintain a relatively normal life, but only after making serious accommodations,”

Patients struggle to make peace with how much they’ve changed and the stigma associated with it, regardless of where they end up.

Post-exertional malaise—severe crashes in which all symptoms worsen after even minor physical or mental exertion is commonly reported.

Many long-haulers try to push themselves back to work and instead “push themselves into a crash,”

Post-exertional malaise is so common among long-haulers that “exercise as a treatment is inappropriate for people with long COVID,”

Even brain-training games—which have questionable value but are often mentioned as potential treatments for brain fog—must be very carefully rationed because mental exertion is physical exertion.

People with ME/CFS learned this lesson the hard way, and fought hard to get exercise therapy, once commonly prescribed for the condition, to be removed from official guidance in the U.S. and U.K.

In summary:

  1. Brain fog can occur even after mild or asymptomatic Covid-19.
  2. Although many patients improve over time, many are left with disability that can range from mild to incapacitating.
  3. Although these symptoms can occur following any viral infection, SARS CoV-2 seems to produce this with greater frequency compared to other viruses.
  4. Chronic brain inflammation is the likely cause in many individuals.
  5. Reactivation of Epstein Barr and/or other dormant viruses is suggested by various immune markers.
  6. The immune signature also suggests an immune response that mimics persistent infection in the absence of live SARS CoV-2 virus.
  7. Post exertional malaise following physical or mental exercise is a common and debilitating symptom without proven treatments. However there are guidelines that may help mitigate this devastating condition.
  8. Brain fog and post-exertional malaise are hallmarks of chronic fatigue syndrome/Myalgic encephalomyelitis which can occur following viral infections and major stress events such as physical and psychological trauma.
  9. Although not discussed in this post, chronically suppressed cortisol levels have been identified in this population. This in combination with physical changes noted on brain MRI demonstrate that there are physical correlates of brain fog.

In the meantime, preventive measures represent the low hanging fruit for health in general and with respect to the pandemic.

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. Supplement with Vitamin D3 to get your levels above 30 ng/ml, >40ng/ml arguably better.
  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/)
  11. Drink water filtered through a high quality system that eliminates most environmental toxins.
  12. If you are eligible for vaccination, consider protecting yourself and your neighbor with a few jabs. Age > 50 and/or risk factors means clear benefit from a booster.

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

Global Food Justice Alliance

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My friend Diana Rogers, started the Global Food Justice Alliance. This organization brings unbiased science to the discussion of meat consumption as it relates to health AND the environment. As discussed previously (see regenerative agriculture posts), properly raised ruminants (beef, pork, lamb, etc.) are ecologically sound, help create soil and fight climate change, and provide important nutrient dense food for people of all ages. The anti-meat narrative in popular media presents a false and dangerous position that threatens our environment, soil conversation/creation, and health.

For more information go here:

Regenerative sustainable agriculture (depicted on the right) , minimizes use of fossil fuel and fossil oil based fertilizer. Instead it utilizes ruminant animal waste for fertilizer, creates living soil and biologic diversity. Mono-agriculture depicted on the left, destroys soil, depletes nutrients in food, contaminates our food with pesticides, creates downstream runoff environmental degradation, and contributes to climate change. The documentary “Kiss the Ground” documents these important concerns.

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. Supplement with Vitamin D3 to get your levels above 30 ng/ml, >40ng/ml arguably better.
  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/)
  11. Drink water filtered through a high quality system that eliminates most environmental toxins.
  12. If you are eligible for vaccination, consider protecting yourself and your neighbor with a few jabs. Age > 50 and/or risk factors means clear benefit from a booster.

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

AHS 2022 Lecture, Acute and Long Covid, Nutritional and Lifestyle Immunology

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I recently gave a talk at the AHS 2022 meeting held at UCLA. You can view the video here:

This first slide gives a good overview.

The presentation covers a quick review of my presentations given last year at the PAH 2021 annual meeting (virtual) with additional information on long Covid.

Multiple nutrients acting synergistically support a balanced response to viral infections, including SARS CoV-2. Here is a picture.

The take home message is that no single nutritional intervention is likely to have significant impact with an acute infection unless all but one nutritional component is optimal. Nevertheless, there is compelling evidence that Vitamin D deficiency is rampant in the developed world and if one nutritional intervention is likely to be of benefit, Vitamin D supplementation, particularly in high risk populations, presents the most likely candidate. As usual, preventive supplementation would be preferable to rescue high dose intervention.

In a study of frail elderly hospitalized patients, regular vitamin D supplementation was associated with decreased mortality as demonstrated here. Compared to no supplementation, regular supplementation was associated with a 93% reduction in risk of death.

A study from Spain with very high dose Vitamin D in the form of Calcifediol showed significant benefit in hospitalized patients, suggesting that Vitamin D deficiency was prevalent in that population and that such a treatment intervention should be widely considered.

Calcifediol Treatment and COVID-19-Related Outcomes

Click to access dgab405.pdf

The following graphic from another nutrition review article, with red additions added by myself, demonstrates the complex interaction between nutrition and the two main components of our immune system, innate immunity (immediate response) and adaptive immunity (based on immune memory). Again red highlights added by yours truely.

And here is a slide from my lecture with quotes from that article.

Yet most Americans are deficient in many of these essential nutrients as depicted here. The percentages represent the % of Americans that fall below the estimated amount required to prevent deficiency in HALF of adults (a very low standard).

The EAR is a very low bar to meet, yet many Americans fall below even that low standard.

The SARS CoV2 virus interferes with a crucial component of the the initial (innate) immune response, the production of interferon 1 and the signaling of interferon one to immune cell mediators as depicted in this graphic.

SARS CoV2 on the left is compared to Virus X on the right. On the left interferon 1 (IFN) production and signaling is blocked by the virus, interfering with an effective and controlled immune response, on the right IFN is not blocked. A cascade of events results in TOO LITTLE, TOO LATE, AND THEN TOO MUCH of an immune response, producing a cytokine storm.

Obesity, insulin and leptin resistance, also interfere with the production and signaling of interferon. The result is that people with insulin and leptin resistance (pre-diabetes, Type 2 Diabetes as well as sarcopenia) experience a double hit. First the virus itself disrupts the immune response and superimposed upon the viral effect is the effect of insulin and leptin resistance on the immune response.

SOCS: suppressor of cytokine signaling. Several recent viral studies have shown that viral genes can hijack SOCS1 to inhibit host antiviral pathways, as a strategy to evade host immunity
On the left Interferon production and signaling are normal and a successful immune response is mounted. On the right the presence of insulin and leptin resistance, associated with obesity results in an initial inadequate response and a late excessive response. TOO LITTLE, TOO LATE, THEN TOO MUCH.

Factors that can quickly impact insulin and leptin resistance include all the components of an ancestral lifestyle depicted in my website graphic. A paleolithic or ancestral diet that eliminates sugar added foods and beverages, replacing those empty calories with nutrient dense foods, exercise, adequate restorative sleep, stress reduction, avoidance of environmental toxins, social connection. All of these affect health in general, mitigate insulin and leptin resistance, and support a balanced immune response to viral infection. The circle of health depicted below is surrounded by the many deleterious aspects of modern living. Thus, a mismatch between our evolutionary biology and present day life.

Here is a slide from my lecture that lists many lifestyle factors that can impact infection with any virus, including SARS CoV-2

My lecture also included discussion of Long COVID, theories of etiology and pathophysiology which will be discussed in my next post.

For the full lecture which is about 34 minutes long, please follow the link above.

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

AHS 2022 at UCLA, I am presenting a talk on COVID-19

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I will be presenting at the next Ancestral Health Symposium, at UCLA, on August 18. The title of my talk will be:

Nutritional and Lifestyle Immunology related to Acute and Long Covid.

AHS includes talks, posters, movement sessions, workshops, and a welcome dinner.

It is a scientific conference but is generally lay-accessible.

AHS covers a wide range of topics, from diet to sleep, breathing, movement, and more — all examined through the lens of evolutionary mismatch

AHS examines various ways modern human life has diverged from how we evolved successfully for millennia and how those differences are affecting us, making us sick and unhappy.

AHS is fun and inspiring, and you’ll leave having made new friends and with new ideas about how to optimize your health

If you decide to join us, please come say hello. Tickets are available through the AHS Website, at ancestralhealth.org — [“Ancestral Health Dot Org”] — where you can also see the three-day schedule for the event, from August 18 to 20.

You can get a 10% discount using the the Eventbrite promo code “PresenterFriend”.

COVID UPDATE FROM Institute of Functional Medicine

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I just viewed an excellent video presentation from the Institute of Functional Medicine providing very useful data on COVID, particularly focusing on the Omicron variants. You can watch it here:

COVID-19 Functional Medicine Resources – The Institute for …

https://info.ifm.org/covid-19

I will summarize the information. But first a few disclaimers.

  1. I have not vetted all of these notes but none disagree with any reports or studies I have read
  2. I have read many but not all of the studies that support these statements
  3. I viewed the video with frequent pauses and replays to facilitate accurate note taking. If you view the video and find any errors please make a comment.
  4. I had a mild case of breakthrough COVID last week and seem to have some brain-fog, feeling like the morning after working most of the night on-call in the operating room.
  5. Many general observations on varied topics related to COVID-19

Omicron Timeline:

11/11/21 Omicron first appears,

1/15/22 Omicron is 99.5% of US cases

1/26/22 B.2 variant appears in US and Europe

2/5/22 B.2 variant 3.6% of US cases

Omicron presents with about 50 mutations, 15 on the RBD (receptor binding domain) with increased affinity for the ACE 2 receptor

Omicron has a cluster of mutations at the S1S2 Furin Cleavage Site. Furin is an enzyme that cleaves the virus to allow for entry into human cells, present in large amounts in the brain, lung and GI tract (thus omicron affecting these organs perhaps more and possibly increasing the risk in people with comorbidities “associated with Furin”.)

Some Omicron mutations are associated with a degree of immune escape, evading anti-bodies and T cells.

B2 may not be picked up by some tests (not discussed in detail)

Compared to B1, B2 is 2.5 times more transmissible in non-VAX folks.

But Vaccine effectiveness against B2 appears to be at least as good or possibly better than effectiveness against B1. (Strange but stated)

Omicron has on average a 3 day latency between infection and symptoms. It appears to replicate “70X more quickly” compared to delta with 3.5 times greater household transmission. Fortunately lung involvement is 10 times lower compared to the original “Wuhan virus”.

Prior infection with delta DOES NOT SEEM TO PROTECT AGAINST OMICRON.

Hospitalization rate with omicron 38/1000 infections vs 101/1000 infections with delta.

In hospital mortality 29% with delta vs 3% with Omicron BUT because of a dramatic increase in transmission with Omicron, daily death rate in US has been 2200 to 2900 per day during the surge, more than delta. (Greater number of infections outweighs the lower mortality rate)

 A preprint study published last month looked at data from about 52,000 people infected with the omicron variant, and about 17,000 infected with delta, in southern California. Compared with patients who had the delta variant, omicron patients had a 53% reduced risk of hospitalization, a 74% reduced risk of ICU admission and a 91% reduced risk of death. The study has not yet been peer-reviewed.

Duration of infection averages 10 days. Estimates for being contagious after onset of symptoms:

5 days 1/3, 7 days 16%, 10 days 5%, therefor some practitioners are recommending isolation for 14 days after onset of symptoms.

PCR can remain positive for months after infection because of non-infectious remnants of viral RNA.

Negative antigen test after isolation is reassuring but does not guarantee patient is not contagious. The home antigen tests were not designed or studied for predicting degree of contagion, only for diagnosis.

LONG COVID can be as high as 30% of all cases, as high as 10% after mild cases.

Vaccination reduces risk of LONG COVID by about 50%.

A study published in GUT demonstrates altered GI microbiome 6 months after infection. The gut microbiome is extremely important for immune function.

One year following COVID infection (previous variants) there is a 60-70% increased risk of heart attack, stroke and congestive heart failure.

In the UK 25% of worker absenteeism is due to LONG COVID.

Infection rates: UNVAX 1000/100,000, VAX 600/100,000, VAX+BOOSTER 300/100,000

A Swiss study showed 98% reduction in death with VAX plus booster.

2/15/22 published study from IOWA showed that 90 minutes of exercise on the day of vaccination increased antibody levels measured 4 weeks after vaccination. Similar data are available for influenza vaccination. I reviewed data on various non COVID vaccine effectiveness relative to sleep and exercise in 2 talks given last year. This result is not surprising.

Individuals with infection from prior variants, but not vaccinated, show no effective neutralizing antibody activity against omicron. (Very worrisome, I will try to vet this one)

Omicron has 4.5 times higher re-infection rate compared to delta.

Omicron infection appears to decrease risk of infection with delta, but prior infection with delta (without vaccination) does not appear to protect against omicron.

Prior infection (before omicron) PLUS vaccination provides 76% protection against omicron infection which is about the same protection of VAX + booster, and this appears to include protection against B2 variant.

T cell immunity after infection (pre omicron) and after vaccination appears to persist and T cell activity increases with time after infection and after vaccination.

Novavax has applied for EUA with the FDA. This is a vaccine made with S-protein particles plus adjuvant (no mRNA).

“The Novavax COVID-19 vaccine, codenamed NVX-CoV2373, is a subunit COVID-19 vaccine candidate developed by Novavax and the Coalition for Epidemic Preparedness Innovations (CEPI), brand name Covovax.”

“Results from a Phase 3 clinical trial enrolling 29,960 adult volunteers in the United States and Mexico show that the investigational vaccine known as NVX-CoV2373 demonstrated 90.4% efficacy in preventing symptomatic COVID-19 disease. The candidate showed 100% protection against moderate and severe disease. In people at high risk of developing complications from COVID-19 (people 65 years or older and people under age 65 with certain comorbidities or with likely regular exposure to COVID-19), the vaccine showed 91.0% efficacy in preventing symptomatic COVID-19 disease.”

Read more on en.wikipedia.org

The US Army is in phase I clinical trial with a multi-valent “ferritin nanoparticle multi-faced” vaccine. This “soccer ball shaped” vaccine has 24 “faces” with multiple variant antigens. Each “face” carries a different antigen.

US Army developing vaccine to fight ‘array’ of COVID variants

“The Spike Ferritin Nanoparticle platform is designed to protect against an array of SARS-CoV-2 variants and SARS-origin variants but was not tested on the Omicron variant,” Walter Reed officials said.

J&J vaccine issues:

The J&J vaccine is associated with a risk of thrombosis-thrombocytopenia (blood clots and decreased platelets). Risk: 1:100,000 doses in women age 30-50. CDC recommends against J&J vaccine unless there is a contra-indication to mRNA vaccine. 15% of these cases are fatal.

A full discussion of therapeutics (drugs) against COVID can be read at IFM.org/COVID

PAXLOVID is an oral combination of two anti-viral medications reserved for adults (age >= 18) with increased risk, given within day 3-5 of symptom onset. It decreases risk of hospitalization and death by about 70% in low-risk and 89% in high risk groups. There are many contra-indications to use including specific medications and supplements (such as Saint John’s Wort). Availability is a problem.

A recent study published in NEJM used IV Remdesivir (daily for 3 days) for early out- patient treatment in high risk patients, reduced risk of hospitalization/death by 87%. This would represent an off-label use of the drug based on a well controlled study.

Home antigen tests on average become positive 3 days after first positive PCR (nasal swab), 2 days after a positive saliva PCR.

The BiaxNOW home antigen test is 73% sensitive (27% false negative rate)

Pregnancy-COVID and vaccination:

A study of 40,000 pregnant women found no increase in pre-term birth, small for gestational age, or any other complication following vaccination during pregnancy.

But COVID infection in unvaccinated women during pregnancy is associated with increased risk for pre-term birth, still born, low birth weight, cesarean section, decreased fetal growth, maternal intubation and death.

Maternal Vaccination produces anti-Covid antibodies found in fetal cord blood at birth.

Intra-uterine demise with COVID is associated with massive placental insufficiency.

There is no data to support decreased female or male fertility following vaccination.

A study of menstrual regularity following vaccination showed < 1 day change in cycle length post vaccination, not clinically significant. Post vaccination regularity equivalent to expected variation in menstrual cycles.

Two months following COVID infection there is a decrease in male but not female fertility rate.

Multiple studies have demonstrated association between low Vitamin D status and risk for severe-critical disease and death. Association does not equal causation but there is biologic plausibility (Vitamin D is a major immune regulator) and consistently increased risk associated with low levels. A recent study demonstrated 14 times greater risk for severe-critical disease in hospitalized patients with levels <20 compared to patients with levels >40. I will update my previous discussion of Vitamin D and COVID in a future post. Spoiler alert: An intervention study with high dose Vitamin D done in Spain demonstrated improved clinical outcome.

Risk factors for poor outcome in descending order:

  1. Age > 65
  2. immuno-compromised state
  3. lung disease
  4. liver disease
  5. kidney disease
  6. neurologic disorders
  7. diabetes
  8. cardiac disease

Patients with severe disease had >= 1 risk factor

78% of patients who died had >= 4 risk factors.

“Nearly two years into the pandemic, unvaccinated Americans are still making up the majority of COVID deaths.”

“Data from the Centers for Disease Control and Prevention shows that during the first week of December — when the omicron variant began taking hold — unvaccinated people were dying at a rate of 9 per 100,000.”

“By comparison, fully vaccinated people were dying at a rate of 0.4 per 100,000, meaning unvaccinated people were 20 times more likely to die of the virus”

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. Supplement with Vitamin D3 to get your levels above 30 ng/ml, >40ng/ml arguably better.
  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/)
  11. Drink water filtered through a high quality system that eliminates most environmental toxins.
  12. If you are eligible for vaccination, consider protecting yourself and your neighbor with a few jabs. Age > 50 and/or risk factors means clear benefit from a booster.

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

Red Meat and Health, another round of nonsense

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Again, another biased article claims to demonstrate the dangers of red meat. There are so many problems with the author’s analysis and conclusions it is hard to know where to begin. Rather than go through the nitty gritty here, just head on over to this analysis to read another debunking of the same litany of bad science.

https://www.globalfoodjustice.org/nutrition/does-the-global-meat-trade-lead-to-poor-health

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. Supplement with Vitamin D3 to get your levels above 30 ng/ml. (read this Open Letter)
  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/)
  11. If you are eligible for vaccination, consider protecting yourself and your neighbor with a few jabs.

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

Long Covid: Vascular Inflammatory Response Mediated by non-classical monocytes.

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Today I listened to Dr. Bruce Patterson discuss his research on Long-Covid.

Bruce Patterson was director of a virology lab at Stanford before establishing Incelldx, a biotech firm in the area of virus diagnostics. Bruce was interviewed today (second half of the program) on The People’s Pharmacy (NPR). The transcript and podcast will be available tomorrow at PeoplesPharmacy.com (show #1273)

Utilizing AI and data from over 10,000 patients, Incelldx has developed diagnostic tools to characterize the immune system dysregulation associated with long covid. According to Dr. Patterson’s research, Long-Covid involves “non-classical monocytes” that are reacting to remnant virus proteins (not RNA or DNA), producing a vascular inflammatory process. That was the missing link. Researchers were looking for RNA, but the problem appears to be in the monocyte reaction to remnant viral proteins that stimulate these specialized monocytes, producing a chronic vasculitis.

Here is a link to the Long Covid clinical program based upon this research.

https://covidlonghaulers.com/

The program involves immune testing by Incelldx and based on the results, treatment recommendations are made.

So far 2 drugs repurposed for long-Covid appear effective when used in combination.

A CCR5 antagonist (maraviroc) which has been used to treat HIV and a Statin medication which blocks binding of the monocytes to artery walls.

According to Dr. Patterson, Long Covid in many patients is a vascular inflammatory process, mediated by non-classical monocytes which are activated by viral remnant proteins.

Dr. Patterson has seen many patients respond to this drug combination. He uses an old, early statin drug (pravastatin) which has a low side effect profile compared to the more commonly used atorvastatin (which gave me severe myopathy, notorious for that problem but understated by drug company reports).

This is cutting edge, most physicians, even in university settings, are not aware of this diagnostic/therapeutic approach.

This is still considered experimental but appears to be very promising.

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. Supplement with Vitamin D3 to get your levels above 30 ng/ml. (read this Open Letter)
  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/)
  11. If you are over age 12 and eligible for vaccination, consider protecting yourself and your neighbor with vaccination.

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

Vaccination risks vs. infection risks, COVID 19

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A recently published study from Israel compared vaccinated vs unvaccinated people who developed COVID 19. The study was huge. It evaluated the absolute risk of various events following vaccination vs no vaccination with COVID-19 infection. The absolute risk numbers are presented as # of events per 100,000 people. The data clearly shows safety of the vaccine and a large difference between vaccination vs no vaccination/infection. The study matched vaccinated individuals with unvaccinated individuals (before the vaccine was available) for various risk factors and followed the two groups for 42 days. Events were recorded during the 42-day study period.

Here is a summary of the findings. The vaccine was the mRNA vaccine (Pfizer).

“We used a data set involving more than 2.4 million vaccinated persons from an integrated health care organization to evaluate the safety profile of the BNT162b2 mRNA Covid-19 vaccine. The main potential adverse events identified included an excess risk of lymphadenopathy (78.4 events per 100,000 persons), herpes zoster infection (15.8 events), appendicitis (5.0 events), and myocarditis (2.7 events).

To place these risks in context, we also examined data on more than 240,000 infected persons to estimate the effects of a documented SARS-CoV-2 infection on the incidence of the same adverse events. SARS-CoV-2 infection was not estimated to have a meaningful effect on the incidence of lymphadenopathy, herpes zoster infection, or appendicitis, but it was estimated to result in a substantial excess risk of myocarditis (11.0 events per 100,000 persons). SARS-CoV-2 infection was also estimated to substantially increase the risk of several adverse events for which vaccination was not found to increase the risk, including an estimated excess risk of arrhythmia (166.1 events per 100,000 persons), acute kidney injury (125.4 events), pulmonary embolism (61.7 events), deep-vein thrombosis (43.0 events), myocardial infarction (25.1 events), pericarditis (10.9 events), and intracranial hemorrhage (7.6 events).

Another particularly notable class of adverse events that has been reported in the context of Covid-19 vaccines is thromboembolic events. These adverse events, which primarily affect young women, have been linked with the ChAdOx1 nCoV-1932 and Ad26.COV2.S (Johnson & Johnson–Janssen) Covid-19 vaccines,33 both of which are adenoviral vector vaccines. However, we did not find an association between the BNT162b2 (mRNA) vaccine and various thromboembolic events in this study.”

We already know that vaccination substantially decreases the risk of severe illness, hospitalization and death. The media has reported on potential, rare complications of the vaccine.  Those reports have frightened some people primarily because when the media report them in a sensational way, they do not compare the risk of the same events with infection. This study demonstrates that the rare complications of vaccination pale in comparison to the risk of the same complications with infection. This study also identifies several serious complications of infection that do not occur as a result of vaccination.

Read the article.

And here is a graphic display of the results:

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. Supplement with Vitamin D3 to get your levels above 30 ng/ml. (read this Open Letter)
  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/)
  11. If you are over age 12 and eligible for vaccination, consider protecting yourself and your neighbor with vaccination.

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

Nutrition and Lifestyle vs Pandemic

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Earlier this year I gave 2 presentations on this topic at the (virtual) annual meeting of Physicians and Ancestral Health, a physician organization dedicated to incorporating evolutionary biology and lifestyle recommendations into the practice of medicine. Here is the first slide:

And here are some very important references:

Please note that this lecture was given before the delta variant arrived so the data applies to the pre-delta period.

MI= Myocardial Infarction (heart attack with loss of muscle), PE=Pulmonary Embolus, DVT= Blood Clots in legs, SIRS= Systemic Inflammatory Response Syndrome

I will skip several of the slides and get to the nutritional immunology and other lifestyle factors.

This slide shows many lifestyle factors that interact with the immune system. The “12% metabolic health” refers to a study demonstrating that only 12% of American adults are metabolically healthy, which will be explained later. Dysbiosis refers to an imbalance in gut bacteria favoring inflammation and immune compromise. The rest should be self explanatory but discussed in detail later in this series.

Here is the very busy slide that summarizes nutritional immunology:

w3/w6 refers to the omega 3 to omega 6 ratio in the diet, ROS= Reactive oxygen species (oxidative stress), CH: carbohydrates; GALT: gut-associated lymphoid
tissue; GPRs: G-protein-coupled receptors; FA: fatty acids; GI/GL: glycemic index/load; RAR/RXR:
retinoic acid receptor/retinoid X receptor; SCFA: short-chain fatty acids; TF: transcription factors; VDR:
vitamin D receptor.

Key points in this slide:

  1. Omega 3 fats from fatty fish fight inflammation, excess omega 6 fats from refined “vegetable oils” (corn, soy, cotton seed, sunflower seed, safflower, etc.) contribute to inflammation and blood clots, contributing to cytokine storm and bradykinin storm.
  2. Vitamin D interferes with the virus at multiple points.
  3. Adequate iron (Fe) from meat and seafood is essential for immune function (Iron from plant sources is much less bioavailable compared to meat and seafood.)
  4. Adequate complete protein (not available from vegan diets) is essential for immune function.
  5. Zinc and selenium (both found in seafood and meat) are essential for multiple protective pathways in the immune system (enhancing response to infection and mitigating excessive inflammatory response as cofactors for antioxidant enzymes)
  6. Sugar and high glycemic foods cause inflammation, high blood sugars suppress the immune system
  7. Dietary fiber supports a healthy gut microbiome which in turn suppresses inflammation and provides the gut lining with SFAs (gut epithelium requires SFAs for energy and function, gut barrier function needs SFAs)
  8. Phenolic compounds in colorful vegetables and berries modulate multiple essential immune pathways that can inhibit viral replication.
  9. Carotenoids, phenolics support several vital immune pathways.
  10. Omega 3 fats are the building blocks of chemicals that help resolve inflammation and mitigate against cytokine storm and bradykinin storm.
  11. Multiple vitamins and phenolics support our internal anti-oxidant system.
  12. To get a balanced protein intake we should eat “nose to tail”. Include connective tissue (home made bone broth is a great source) and organ meats (from grass fed/finished ruminants) in addition to muscle meat.

Here is another busy slide that presents more detail, note the reference at the bottom of the slide to read more.

Sorry for the small print but you can see the blow up on line by going here.

http://A Review of Micronutrients and the Immune System-Working …

So does the “Standard American Diet” meet these nutritional needs to support a healthy immune system?

The % above represent the % of American adults with intakes BELOW the EAR (Estimated Average Requirement) for various vitamins and minerals. But note the definition of EAR:

“nutrient intake value that is estimated to meet the requirement of half the healthy individuals to avoid symptoms of a clinical or subclinical deficiency” (NOT OPTIMAL LEVELS for immune function)


Note also that this study did not consider omega-3s, phytonutrients, flavonoids, polyphenols, fiber, etc., all of which are essential to a robust immune response to any virus including SARS CoV-2.

With regards to omega 3 vs omega 6 fats:

Omega 3 fats (EPA and DHA) found in seafood fights inflammation, blood clots. DHA and EPA are the building blocks of SPMs which help RESOLVE INFLAMMATION (MITIGATE CYTOKINE STORM)

We will return to this topic in my next post. We are just scratching the surface of a complex system.

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. Supplement with Vitamin D3 to get your levels above 30 ng/ml. (read this Open Letter)
  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/)
  11. If you are over age 12 and eligible for vaccination, consider protecting yourself and your neighbor with vaccination.

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

Red Meat: Good or Bad?

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There remains a strong bias against the consumption of red meat in published dietary guidelines. The evidence supporting claims of increased risk of cancer or heart disease remains very weak and suggests at most a 1% absolute risk increase based on very weak evidence. Significant factors are almost universally ignored in the analysis. These include:

1. Use of hormones in raising animals

2. Grass fed and grass finished vs grain fed- feedlot fattened animals

3. Use of antibiotics

4. Methods of cooking

5. Processed-refined meats with added sugars/preservatives vs fresh or frozen unprocessed meats.

6. Confounding factors such as smoking, exercise, and other lifestyle factors

7. Poor accuracy of dietary questionnaires

8. Poor study design.

9. Residual pesticides in animals passed through feedlots.

These considerations are all important in determining the health benefits of consuming animal fat and protein. The 1% absolute risk increase discussed above relates to consuming meat raised in the typical US fashion. That includes the regular use of hormones, antibiotics, and feedlot conditions. Feedlot conditions dramatically change the fatty acid content of beef to a less healthy mix. I do not consume meat that passed through feedlots.

Prior to WWII, meat and poultry were raised without hormones, without antibiotics. They were pastured and free range. Ruminants ate grasses not grains, which cause gastro-intestinal problems in ruminants. Poultry ate bugs, grass, seeds in an open air environment. Crowded disease causing conditions were not prevalent in animal husbandry. Today things are different and one would be wise to make their consumption choices speak for healthier sources of animal protein and fat.

I have always advocated for avoiding animal foods raised with indiscriminate use of antibiotics and hormones, animals raised in crowded unsanitary conditions, ruminants (beef, lamb) fed grains, etc.

But beyond those considerations, unprocessed red meat provides an abundance of important nutrients vital to health.

A discussion of the bias that underlies many dietary guidelines is covered in a brief and informative video:

I have previously discussed the false narrative about environmental concerns related to beef, recommending the book and documentary by the same name, SACRED COW.

You can read that here.

Dr. Georgia Ede addresses the issue of red meat in many of her talks. Here is one.

She has also posted a discussion of brain health and animal fat.

And she has debunked the concept that meat causes cancer.

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. Supplement with Vitamin D3 to get your levels above 30 ng/ml. (read this Open Letter)
  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/)
  11. If you are over age 12 and eligible for vaccination, consider protecting yourself and your neighbor with vaccination.

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