Pandemic Perspective #35 November 21, 2020

Could COVID-19 be a turning point in the obesity epidemic?

            In nearly a year since SARS-CoV-2 invaded our lives it has established itself as one of the deadliest plagues of mankind. By this year’s end it will have infected more than 60 million persons worldwide and will have killed more than 1.5 million persons. These figures are far below the catastrophic numbers of the influenza pandemic of 1918-1919. The most conservative estimates place that death toll at 40 million while others claim it to be 100 million at a time when the world’s population was only 1.8 billion, less than a third of today’s figure.

            As one who has watched the explosion of obesity and type 2 diabetes during a medical career that began more than 60 years ago I find myself wondering what the death toll would have been like if our grandparents were as fat-challenged as we are. After all, we have known for a couple of decades that overweight and obesity are critical risk factors in influenza, nearly doubling the mortality rate.

            The publication of more than 500 medical journal articles so far in 2020 has made it obvious that obesity is a major comorbidity in the current pandemic. Obese patients are nearly twice as likely to require hospitalization, to be admitted to an intensive care unit and to be intubated. A rather bizarre indirect indicator of this phenomenon is the job requirement that morgue workers should be able to lift bodies weighing more than 175 pounds!

            It is not only the scientific community that has become aware of the dangers of excess weight. This knowledge has apparently begin to percolate among the masses. (Forgive the inadvertent pun!) At the same time the lockdown and its consequences — people staying at home, being less active, eating and drinking more, locked out of fitness centers – have led to weight gain. I’m not sure if Weight Watchers and similar groups have seen an increase in membership but medical centers that specialize in bariatric surgery are reporting that they are receiving more inquiries from potential patients.

            Could COVID-19 be the tipping point that marks the reversal of the twin epidemics of obesity and type 2 diabetes? That may be a bridge too far but we can hope that it will encourage at least some thinking individuals to make some lifestyle changes. One of these changes might be the use of fasting, which I discussed in the November 15th Carvings and that I’ll explain further in the December 1st blog.    

In the news

As if you needed another reason to get the flu shot.

            Influenza is a nasty disease that kills, on average, about 40,000 Americans each year and it’s no respecter of age. It kills the young as well as the old and pregnant women are especially vulnerable. As noted in previous blogs, obese persons, who now account for approximately 40 percent of our population, have double the risk of dying from influenza.

            The flu season for 2020-2021 seems to be off to a slow start, possibly because of the mandated as well as the self-imposed restrictions on person-to-person contacts during the COVID-19 pandemic. Don’t let that make you complacent; there is no way to predict how serious this year’s strains of influenza are likely to be.

            Considering the mild side effects of the current influenza vaccines – usually little more than a sore arm for a couple of days – it’s important to recognize what the benefits of this vaccine really are. They go far beyond simply making the disease milder; even the best vaccines prevent the disease entirely only about half the time – in a good year! Most people are not aware that vaccinated persons are much less likely to require hospitalization and thus avoid the risk of becoming infected with one of those antibiotic-resistant bacteria that are becoming more prevalent and more deadly.   

            Persons with an underlying heart problem have another benefit from the vaccine. Following influenza there is a marked increase in their risk of a heart attack, congestive heart failure or stroke. The opposite happens in vaccine recipients: there is a reduction in cardiac events in the months following vaccination, ranging from 19 to 50 percent in published studies, as well as a 48-50 percent decrease in all-cause death.

            Finally, following a bout of influenza there is a decrease in cognitive function. For many of us, that’s the one that really matters!

Lifestyle

Intermittent fasting. Is the bloom off the rose?

            A couple of years ago various regimens for fasting in order to lose weight were flooding medical journals. Today, not so much.

            Fad diets are aptly named – they are fads that cannot be sustained over a lifetime. So when intermittent fasting came along – after all, its proponents maintain, ancient humans were forced by their environment to go for days, even weeks, with very little food so it must be normal — the bandwagon became overloaded with so-so results and most enthusiasts fell off.

            A major problem is that there is no agreed-upon standard for “intermittent fasting.” A day, two days, every other day? They all get old eventually and there’s no way everyone in a family will always follow the rules. Emerging from all this is a report from researchers at UCSD that might show a way that works:  the 14-hour fast.

            They report on a small – very small – group of overweight women (no men) who were placed on a schedule in which they fasted for 14 hours every day. They didn’t change their diet but they only ate during a ten-hour window from the start of breakfast to the end of dinner.  Over the three months of the study they averaged a weight loss of a whopping two pounds a month – not very impressive at first blush. But if one can maintain that weight loss over about two years that’s about 50 pounds. Now we’re talking!

            When translated into what the average person can do to get similar results, it means not eating anything from about 7:00 in the evening to about 9:00 the next morning. That doesn’t quite work out for folks with a job or with kids that have to get to school (whenever that might eventually be!). Suppose we aimed for a 12-hour fast? I’m willing to bet that it would be almost as effective, and going from 7:00 in the evening to 7:00 in the morning without even a snack is no big deal.

            But there’s more to the story. The study participants reported that they slept better, no big surprise since we have always known that eating before bedtime makes for poor sleep. They also found that this regimen was easier than counting calories or exercising more, so much so that about one-quarter of the group decided to continue that 14-hour fast lifestyle and another third said that they would follow it at least part of the time.

            But wait – there’s more! Even though the experiment lasted only 12 weeks, there were significant, i.e., more than 10 percent, reductions in total cholesterol and LDL cholesterol, as well as smaller but significant decreases in blood pressure.

            This is but one of several studies on 12-14-hour fasts. On the December 1st blog I’ll explain why it pulls together much of what we already know about this type of fasting.

Pandemic Perspective #34   November 14, 2020

Covidiocy by the numbers

            San Diego crossed an important threshold this week; we have passed the magic number of 7 – the number of new cases of COVID-19 per 100,000 residents per day, placing the region in the tier that requires resumption of restrictions that are health-damaging and economically devastating. We are at 8.9 and various public venues will be on lockdown again beginning today. It is certain that some businesses will not survive this new clampdown, and some San Diegans will not, either.  

            It’s not my intention to dismiss the seriousness of the situation that we are in, a rise in cases that will strain healthcare facilities and personnel in several parts of the country, including ours. Influenza is joining the attack and that will certainly make things worse. My concern is that decisions are not being made thoughtfully, fairly or evenly and that such responses are inviting not only resentment but anger and refusal to adhere to the guidelines.

            The media report that hospitals are reaching capacity in some parts of the country but that is certainly not true in San Diego. According to the tracking information provided by the San Diego Union-Tribune (www.sandiegouniontribune.com/tracking-coronavirus-cases-san-diego-county) the county’s available bed capacity is approximately 2,000 while those currently occupied by COVID-19 patients is about 400.

            San Diego County is the second largest in the state both in area and in population. Public health authorities shouldn’t consider it as a single entity when assessing risk of coronavirus infection. For instance, most cases by far have occurred in the South County, where restrictions might have a greater effect than in North County, which has experienced many fewer cases and fewer deaths

            The strictures applied to different businesses and organizations are frankly bizarre. Consider that fitness centers are closed or restricted but casinos are open. My local fitness center clientele is predominantly young, healthy and not obese. The risk of death or serious illness among those who work out there is almost zero. There have been only four COVID-19 deaths in the entire county among those aged 20-29 since the onset of the pandemic.

            How about those casinos? Many if not most of their customers fit the all-American profile: older, overweight or obese, diabetic, smokers, with at least one marker of coronary artery disease. Does the term comorbidity ring a bell?

            Of course, if you are stressed out by fear of the virus or of losing your job you are welcome to stop by your local pot shop. It’s still open.

Pandemic Perspective #33   November 7, 2020

Antibody Angst

          There has been a flurry of worrisome articles suggesting that infection with the virus of COVID-19 produces antibodies but that they decline rapidly, possibly to unprotective levels. The implication is that a vaccine will either be ineffective or that it will protect recipients for only a short time. Although these conclusions are possible they are at the moment unknowable, and in my opinion, unlikely. Not only will we have to await the analysis of a large number of re-exposed individuals, current testing methods will have to be refined, meaning that they will become more accurate and reliable.

            Antibodies that the body makes in response to an infection or to a vaccine always decline eventually, sometimes to levels that are below the threshold of the laboratory tests that identify them. The immune system is remarkably complex, having evolved over millions of years to have many different mechanisms that provide redundancy that any engineer would be proud of. If you become a victim of the coronavirus your antibody response will depend on your genetic profile, your nutritional intake, your body fat percentage (obese persons respond significantly less well to vaccines than do persons of normal weight and possibly to natural infection as well), your level of physical activity and your past exposure to similar viruses. Then there’s the matter of the particular strain of coronavirus that you encountered and which mutations it has undergone.

            I have observed that pessimistic journalists’ reports do not mention another – and possibly more important — arm of the immune system, cellular immunity. Some cells of the immune system store information that can be retrieved when the same or similar virus tries to attack. Knowledge of how these cells work is limited by the fact that they are harder to investigate than the antibody system and there is as yet no test available to clinicians that would help them to evaluate the cellular immune status of their patients.

            There are silver linings behind the COVID-19 cloud. One of these is that in the next couple of years we will have detailed knowledge of how the body responds to infections in general and this novel coronavirus in particular. In the meantime, keep in mind that antibodies are only one element in a vast and incompletely understood response to infections.

In the news

The Great Barrington Battle

            The picturesque town of Great Barrington, Massachusetts has been sucked into the COVID-19 maelstrom. A document entitled The Great Barrington Declaration was released on October 4, 2020, authored by scientists from Harvard and Stanford universities and the University of Oxford. Co-signers include more than forty scientists whose interests involve microbiology, epidemiology, psychiatry, genetics, medical ethics, immunology, vaccine technology, biostatistics and public health policy. More than 500,000 persons have voiced support of the declaration, including more than 40,000 physicians and other scientists. These are arrayed against large numbers of individuals of similar backgrounds, also respected experts in their field, who are opposed to the opinions expressed in the document.

            The main elements of the declaration are two-fold: those who are at minimal risk of death should return to a normal way of life, are likely to experience infection and thus eventually build herd immunity; those who are at high risk, namely persons who are older, obese, diabetic or who have other comorbidities, should be protected, a concept called Focused Protection.

            Opponents claim that about 60 percent of the population has comorbidities such as being overweight or obese and having diabetes, and that it is simply not possible to protect these and the vulnerable elderly. They include Dr. Anthony Fauci, Dr. Adhanom Tedros, an immunologist and Director-General of the W.H.O., as well as spokespersons of the Infectious Diseases Society of America. With such acknowledged authorities so heatedly opposed to each other, what is the public to believe about an issue that is clearly having a serious impact on the health, finances and morale of the entire population?

            Like so many contentious issues there is truth on both sides. First, the mortality rate among the youngest of our populations is vanishingly small: as of late October the CDC has reported only 79 coronavirus fatalities among children below the age of 15. Among those below the age of 25 the number is only 462 and a large percentage of them also have comorbidities, including heart and lung disease as well as obesity. In four recent publications the percentage of children who died with comorbidities ranged from 22 to 83 percent. These are tragedies to be sure but only a tiny fraction of the more than 235,000 Americans who have succumbed to COVID-19 since the start of the pandemic. If all children are able to return to regular classrooms their risk is small but that leaves open the possibility that they will infect older relatives and teachers who might have comorbidities.

            Herd immunity is a major point of dispute. As I noted in an earlier blog the likelihood of herd immunity as a result of the natural spread of infection is nil or nearly so. Barely three percent of the U.S. population has been infected to date. Only a vaccine can accomplish herd immunity and there is no certainty that most people will receive or even want to receive the vaccine and that the vaccine will provide long-term protection. On the latter point it will take most of 2021 before we can have solid information regarding the duration of protection; only natural challenges among vaccine recipients will reveal that and the wide diversity of vaccine types will obscure the results even longer.

            In my opinion, opening schools will expose some susceptible persons to infection but keeping them closed has its own perils and appears to be a greater risk. The vast majority of outdoor venues should be opened with the same caveats that the elderly and medically compromised among us should limit their exposure. Weight-challenged persons will suffer inordinately but they face the same perils from influenza – and children die in much greater numbers from influenza than from the coronavirus — and those annual epidemics that carry off on average about 40,000 Americans every year have not required schools and businesses to close.

            As always, I appreciate your feedback.

Lifestyle

Dr. Phil’s Senior Shake – an antidote to some of the Annoyances of Aging that have been reviewed in this blog.

            Geriatric specialists are well aware that older persons, especially those who live alone, tend not to have a well-balanced, nutrient-rich diet. Here’s my breakfast recipe – an easy way to start the day that will provide you with some important dietary factors. These include protein, fiber, healthy carbohydrate, calcium and antioxidants.

            I use an ordinary kitchen blender with a capacity of six cups, a three-day supply. I start with about four ounces of orange juice or one of the OJ blends (strawberry, banana, mango, etc.) to give it some extra flavor without much sugar and add about 16 ounces of water.

            Add a banana and some colorful fruit such as blueberries, strawberries or raspberries. The more color, the more antioxidants. They also provide flavor and fiber. Frozen packages of mixed berries are especially convenient.

            MOST seniors don’t get enough protein that is so vital for tissue repair and a strong immune system, so I include at least 30 grams of protein powder (that comes out to about 10 grams per serving) of which there are many types in every supermarket or health food store. Stick to name brands with no added flavor. (You’ll get plenty of that in the fruit.)

            Yogurt is next, mainly for the protein but also for the calcium. My favorite is Trader Joe’s Greek non-fat. There are so many different flavors that you’ll never get bored.

            The last three ingredients are for intestinal health: Miralax, Metamucil and a probiotic powder. You might not need the first two but hardly anyone gets enough of the good bacteria that are so essential.

            If you’re looking for more information on protein powders and probiotics a reliable source of unbiased information is http://www.consumerlab.com.

            What about veggie shakes? They sure worked for Jack LaLanne! He made it to his mid-90s!