About stoneagedoc

Pediatric infectious diseases specialist, author and public speaker. After 35 years in clinical practice including 40 years in academic pediatrics I now share that experience in helping others to enjoy a long, healthy life without the burden of chronic disease.

 Carvings                February 1, 2021

In the news

            Does it seem logical to wear a mask after you have received the COVID-19 vaccine?

            “I honestly don’t think I’ll ever go without a mask at work again,” says Dr. Eugenia South, emergency physician. At first glance this doesn’t seem to make sense but we need to look at her statement in context, especially the words “at work”. Healthcare workers are at extremely high risk for several reasons. They spend many hours a week in the presence of the sickest COVID-19 patients, those that are shedding large amounts of virus as they cough and breathe rapidly. Physicians have known for decades that a large dose (called an inoculum) may cause more rapid and more grave illness. E.g., a small amount of a poison will make you sick but a large dose will do you in. The protective gear that caregivers wear for many hours at a time is uncomfortable and unless it is donned properly and adjusted frequently it causes exposure to infection. That especially applies to medical-grade face masks. Caregivers have been under the kind of stress that few of us can appreciate and they have been doing this for nearly a year. Chronic stress can lower the immune system; in a high-risk setting it can be fatal, as the large number of healthcare workers who have died has shown. Dr. South has undoubtedly received a vaccine but there are other considerations that she is surely aware of.

             First, very few vaccines are 100 % effective. Persons who are immune-compromised have a poor response to vaccines and so do persons who are obese – currently 42 percent of U.S. adults. That’s a lot of poor-responders. Sometimes the specific sample of the vaccine is ineffective because of improper storage. This occurred a couple of decades ago when the measles vaccine was kept in refrigerators whose door shelves were not cold enough to preserve the vaccine. The first two coronavirus vaccines released so far have extremely low temperature requirements for storage. Some facilities and some personnel may not be as competent as they should be. The risk of vaccine failure for this reason is probably small but it is real.

            There is considerable fear among healthcare workers and the general public that these are unproven – some use the word “experimental” — vaccines. We have enough evidence that the vaccines now being distributed provide a strong protective response and serious side effects have been uncommon and treatable but there’s more to the story. Will we see serious side effects in the months or years to come? We don’t know. If vaccine recipients are exposed to the natural virus next year will they be protected or will they have even worse disease? We don’t know. How long will protection last? We don’t know.

            Dr. Tom Friedman, former director of the CDC, is concerned that vaccine recipients might be free of disease after later exposure but if they are reinfected they might still be able to transmit the virus to others. Again, we don’t know, but my personal feeling is that the risk of that is very low.

            All viruses mutate but so far it seems that the current mutations do not negate the protective effects of today’s vaccines. Could that change? Of course, but vaccine developers are watching that closely and may have to modify their product. We do that every year with the influenza vaccine.

            Let’s assume the best-case scenario: the vaccine that you received caused nothing more than a sore arm and feeling punk for about a day. The vaccine will prevent you from becoming ill with this virus for at least a year. Studies later will show that you cannot transmit the virus to others. The virus is stable and you don’t need another variant of the vaccine.

            You won’t get complete protection even in this best-case scenario for at least a month after your second dose and you could be infected – and infectious – until then. It is this fact that has prompted the warning that we need to keep wearing a mask after vaccination. Less worrisome reasons are those that I mentioned above: faulty vaccine and mutations.

            If you are in a vulnerable group, i.e., over 60 years and/or with a comorbidity such as obesity (I include overweight), diabetes, heart disease, hypertension or kidney disease, get the vaccine as soon as you are able. If you are young and healthy I suggest waiting until those who are not have been protected, which will probably take until about April 2021. By then we should have answers to most of the questions that are of concern to those who have been refusing the vaccine until now.

            That is, of course, unless this rascal of a virus unleashes another surprise!

Lifestyle

            Snacks can make or break a diet. The kind that you find while you’re standing in line at the checkout counter are probably the worst, even the trail mix or beef jerky. Some trail mixes have well over 100 calories per ounce and a piece of beef jerky that weighs a little more than a half-ounce can contain as much as 440 milligrams of sodium – about 20 percent of what you should allow yourself in a whole day.

            The ideal snack should contain enough fiber or protein to satisfy your appetite. A piece of fruit averages only 50 to 75 calories but the fiber leaves you feeling full. A single handful of nuts, especially almonds or walnuts (for the engineers and accountants in the audience that’s about 12 pieces or about ½ ounce) will provide about 80 or 90 calories. That will also give you some protein and some omega-3 fats, both of which will give you a feeling of fullness – especially if you eat them slowly!

            Diet gurus sometimes recommend a tablespoon of peanut butter on a stalk of celery. Nice theory but who has the time to make it – and not find something else that’s more appealing and convenient in the refrigerator to nibble on, like ice cream?

            Dried fruit? Not such a good choice because it’s high in sugar. After all, 6 apricot halves are the equivalent of 3 whole apricots, and four prunes are the equivalent of four plums. Do you usually eat that many pieces of fresh fruit at one time?

Carvings                      January 15, 2021

The risk of COVID-19: it’s not just being old

            The pandemic has taken a dreadful toll among the senior population. The vast majority of deaths have occurred among persons over the age of 65. One estimate is that about ten percent of persons living in senior facilities have died, at least indirectly, from COVID-19. San Diego County is an example; 88 percent of deaths have occurred in persons over the age of 60. Those below the age of 40 account for only 1.1% of the fatalities.

            If age were the most important factor those over the age of 100 would surely have zero chance of survival. Yet as of the middle of January there have been at least two hundred people over the age of 105 (!!!!) who have tested positive for the virus and remain alive. The oldest confirmed survivor is a 113-year-old woman in Spain, a country that has suffered severely during the pandemic. Maria Morera is not obese or even overweight and thus has none of the diseases that are the consequences of having excess body fat and that play a major role in a morbid outcome. The oldest woman in Spain, she is bright-eyed and alert, noting that “I am old, very old, but not an idiot.” What an inspiration!

            Maria is fortunate in having an immune system that is strong enough to have overcome COVID-19. Not all seniors are so lucky; aging itself does take a toll on the immune system. However the stark truth is that most older persons are overweight or obese, triggering other comorbidities. Some have lost weight as they have aged but not the burden of their past: type 2 diabetes, heart disease, coronary artery disease and poor kidney function. These are the classic comorbidities of COVID-19. Another is chronic obstructive pulmonary disease (COPD) because nearly half of today’s seniors were smokers; smoking history accounts for nearly 90 percent of that lifestyle-destroying affliction.

            At the time of the last great pandemic, the influenza scourge of 1918-1919, about five percent of Americans were obese; that number is now an appalling 42.4 percent. In addition to contributing to the comorbidities mentioned, excess body fat adds fuel to the pandemic fire in two other ways. Fat tissue contains cells of the immune system and the more fat the more of these cells. During infection with SARS-CoV-2 these cells produce an overreaction, the cytokine storm that is almost always fatal.

            As noted in earlier blogs, COVID-19 victims who are deficient in vitamin D are several times more likely to be infected with the coronavirus, to require ICU care and to die. Vitamin D is critical for normal immune function but fat tissue acts as a vitamin D sink, preventing this hormone-like chemical from exerting its protective effect.

            Finally, what if the rate of obesity were the same today as it was during The Great Influenza of a century ago? Think about it.

Lifestyle

            Taking in less sodium isn’t going to do much for weight loss but it will certainly improve your overall health.  Americans take in about 5 times (!) as much sodium as they need, contributing to the current epidemics of high blood pressure, heart disease and osteoporosis.

            The sodium intake of hunter-gatherers in Africa is about 600 milligrams per day and the incidence of hypertension (high blood pressure) in that group is almost zero. The diet of their genetically identical cousins in the United States contains about 3500 milligrams of sodium each day, a major factor in the very high incidence of hypertension among blacks in this country.

            Most of our daily sodium intake comes from packaged, processed food. That’s why it’s so important to read the Nutrition Facts label on every package. If the sodium content is over 500 mg. (milligrams) per serving, take a pass.

            There are plenty of tasty substitutes for salt but potassium chloride isn’t one of them. Most users complain about the taste. However, there are plenty of spices that you can use to brighten up your menu. Just start experimenting.

            When you cut back on salt you’ll notice that you start losing your taste for salty foods in just a few weeks. If you are one of the 20 percent of Americans that are salt-sensitive you’ll also find that your blood pressure is coming down as well. That lowers your risk of heart attack and stroke, which together are the leading cause of death.

Pandemic Perspective #39     January 9, 2021

COVID-19 – Still a mess!

            SARS-CoV-2 is providing humanity with more twists and turns than any novelist could dream up. Among a myriad of different kinds of tests none is reliably accurate. We don’t even know how many Americans have been infected. The official number cited by the Johns Hopkins Coronavirus Resource Center on January 8th was nearly 22 million, more than six percent of the population, but some epidemiologists state that the actual number may be ten times as high. (BTW: when you see a number that ends in zero you can bet that it is a guesstimate, not an estimate.) We don’t know if persons who have recovered from the infection will have permanent immunity or whether the vaccine will provide that either. Of course, with the number of vaccine candidates now more than 200 it will be a very long time before we know which one is best and how much protection each one will provide. Can a person be infected more than once? Yes, but the number is reassuringly low, at least at the moment!

            So is there any good news? Yes, namely that the first two vaccines that have been released have an effectiveness of about 95 percent – better than many vaccines, especially the one for influenza. In one trial thirty persons developed severe infection but they were all in the placebo group; none of those who received the actual vaccine became seriously ill.

            More good news is that by the end of 2021 most of the U.S. population will have received a vaccine. There has been a lot of criticism of state and federal authorities for their seeming sluggishness but in the larger picture the delay of a month or two in the face of the worst pandemic in a century is (in my humble opinion) acceptable. My reason for giving them some slack is not just the enormity of the task but that these vaccines require storage and transport at extremely low temperatures that most of the medical facilities in the country have never needed to consider.

            One final confounding issue: if you have had a documented infection with this coronavirus, should you still receive the vaccine? The prevailing opinion among virologists, immunologists and epidemiologists is yes. They note that some persons do not develop lasting immunity in the course of infection. Some scientists feel that the immunity produced by the vaccine is stronger and more consistent than that formed by natural infection. That is counter to what we know of most viral infections, a reminder that this virus is not like any other.

            The controversies and confusion that marked 2020 are not going to go away soon. We might shed our masks this year but not our wariness. Most of us will probably continue to limit interaction with persons beyond our circle of family and close friends. But we will do that in our our favorite restaurant!

Pandemic Perspective #38       January 2, 2021

Time to double down

            I am usually an optimist but I’m deeply concerned about what we are facing in the first couple of weeks of this New Year. Public health authorities warned us that the surge in travel that began in the days before Christmas would result in a corresponding surge in coronavirus infections – and deaths. They were correct. On New Year’s Eve 585 Californians died, 62 of them in San Diego County, where 4478 new cases were recorded. These numbers are far higher than those we experienced earlier. Holiday travel is about to end but the effects of all that people movement will continue for most of this month. There has never been a more important time to lower your exposure to the virus.

            Pandemic fatigue and frustration are fueling anger and resistance to burdensome restrictions. The hypocrisy of government officials at every level doesn’t help. Through all this however we need to maintain pandemic precautions. In the matter of COVID-19 vaccines I remain an optimist: by the start of summer the most vulnerable Americans and those responsible for caring for them will have received a vaccine. It’s critical for us to hang in until we get our turn.

            I noted in previous posts that masks are only somewhat protective. In addition to that small but real benefit a mask is a reminder to follow other precautions. They do help to prevent the spread of infection, as noted in a recent meta-analysis and three other studies but masks only work if they are the proper type and are worn correctly. Single-layer cloth masks are virtually worthless and wearing even the best-quality mask won’t help if it sits below your nose, mouth or chin – as, I’m sure, many readers have observed in public places. In my daily visit to the (outdoor) fitness center such aberrant mask discipline is frustratingly common.

            Think about all the ways by which you can minimize exposure to other persons, not just by maintaining that questionable six-foot spacing. Cut back on shopping trips. Stretch those trips out to 10-14 days, not every week. Go when traffic is lightest – early morning or late evening. If you are part of an at-risk group consider having groceries delivered at least sometimes, or have someone get your groceries or other necessities.

            Take a walk most days of the week. Think of the benefits. Just getting out of the house is important and if you still work outside the home, park farther from your job than you used to. And don’t wear a hat so that you will get a dose of vitamin D by keeping your head and face exposed. For the next few months, forget the sunscreen. 15-20 minutes of sun exposure three or four times a week will not increase your risk of skin cancer. Check with your dermatologist if you have had skin cancer or you are of Scottish-Irish-English ancestry (or if my suggestion makes you uncomfortable!). If you live north of a line that connects Los Angeles with Atlanta your body’s ability to form vitamin D from sun exposure is almost zero. For that reason and because there is increasing evidence that vitamin D deficiency is associated with a poor outcome from COVID-19, researchers in that field strongly advise that everyone should take a minimum of 1,000 units (50 micrograms) of a vitamin D supplement every day.

            There are two other reasons for walking and other types of exercise: physical activity boosts the immune system and also improves the function of your heart and lungs. 

            This coronavirus is going to circulate around the globe for years but as happened after the worst years of the 1918-1919 influenza epidemic, people, especially the media, will stop paying attention to it as the cases drop significantly.

            Don’t let your guard down, especially now.

Carvings                 January 1, 2021

In the news

Does “Warp Speed” give you the jitters?

            Depending on the source of the report about 30-40 percent of Americans say that they will not get the COVID-19 vaccine. Many of them are concerned that the vaccines – of which there are dozens in the pipeline – were designed hurriedly, use methods that have never been tested on humans and side effects are unknown. How realistic are these fears?

            The many candidate vaccines use a variety of designs and some of them are unique. The ones recently released by Moderna and Pfizer use mRNA technology. This messenger RiboNucleic Acid molecule is necessary in the formation of proteins on which life depends.

            These mRNA vaccines are hardly new. Work began on them nearly 30 years ago during which time the technology has been refined, testing has been done on thousands of animals and against many viral diseases. Prior to the recognition of the current pandemic there were very few studies in humans but in more than 100 subjects there were no serious adverse events. More than 100,000 persons were included in the trials of current vaccines and as of this date more than 5 million persons have received one of the new vaccines. The most serious side effects have occurred in persons with known allergies for whom appropriate treatment was at the ready. That resulted in an advisory that persons with known allergies should not receive the vaccine.

            In past vaccine development, testing phases were done sequentially. These phases have now been done in parallel, shortening the process. “Warp Speed” meant that some manufacturers revved up their production and distribution programs even before the vaccine materials were available. That term, which has become politically pejorative, does not apply to the science behind these vaccines.

            Few vaccines are completely free of side effects if that term includes a sore arm. Such soreness actually indicates that the body is processing the vaccine. In fact, someone who experiences a lot of soreness, fever and a day or two of feeling lousy is probably someone who would have been really knocked out by the natural infection.

            By the time frontline healthcare workers, military personnel and a few privileged politicians have been vaccinated the rest of us will be able to decide whether these vaccines, of which we will have a choice of several, are safe.

            This virus has shown itself to be full of surprises and the rollout of the vaccination program will probably reveal a few more. At least for now the newly-discovered and more highly transmissible variant appears not to require a change in vaccine technology or strategy. Let’s hope that it stays that way!

Lifestyle

Exercising to lose weight? Don’t count on it.

            I would guess that the number of folks who have made a New Year’s resolution today to lose weight is setting some kind of unofficial record. (Have you seen those Internet photos of post-COVID Batman or Mona Lisa?) The title of this section isn’t as negative as it seems. Exercise is a critical element of a weight-loss program but not for the reason that most people think.

            The most effective way to lose weight is not to eat less but to eat fewer calories. In order to stifle diet-killing cravings that means eating food that fills you up, not fills you out. Replace calorie-dense foods made from refined flour and sugar with calorie-sparse vegetables and fruits. (I know – fruit contains sugar but an apple or a banana contain roughly 75 calories, about as many as you will find in 1 ½ Oreo cookies or one-third of a Krispy Kreme donut. You can probably polish off four or five Oreos and a couple of donuts but you’ll feel really stuffed after three apples or three bananas. And nobody stops at 1 ½ Oreos or a third of a donut!)

            That strategy can shave off 500 or 600 calories a day without leaving you feeling hungry but much of the weight that you lose will include lean body mass, mostly muscle. Regular exercise will keep that from happening so that you will retain energy, muscle mass and bone mass. Without exercising regularly a low-calorie diet will leave you feeling sluggish and it will eventually lead to osteoporosis.

            A warning: as you lose fat and gain muscle it will seem like you’re not losing weight, a frustrating experience. But you will also find that your waist size is getting smaller because fat takes up more space than muscle.

            And isn’t that a nice trade-off?

Pandemic Perspective #37      December 20, 2020

            This is the last Pandemic Perspective of 2020 and I’d like to make it as positive and forward-looking as is realistic, considering the enormous toll that this virus has taken in less than one year.

            First, although this observation has some easily challenged elements, the fatality rate has decreased dramatically since April 2020. I began recording the statistics from the Johns Hopkins Coronavirus Resource Center when the global fatality rate was 7.2 percent; it is now 2.2 percent. In the U.S. the rate has fallen from 5.8 percent to 1.8 percent. In San Diego County it is 1.0 percent. Unfortunately, reporting is far from accurate but the trend is clear. Perhaps most of the seeming improvement is because testing has increased dramatically. Also, most of the deaths have occurred among the elderly who were not adequately protected in the early months of the pandemic. They are still the most vulnerable group but better safeguards are in place. A third factor is that physicians are simply getting better at treating the disease: more skillful ventilator use, antiviral drugs and other medications such as steroids and anticoagulants.

            The vaccine rollout has begun and in spite of political wrangling we may see that half the U.S. population will have been immunized by the start of summer. But there’s more to the story. The development of a variety of new vaccine technologies promises that the control of infectious diseases will have made a quantum leap that would not have occurred without the stimulus of this pandemic. Innovations in logistics will benefit us when the next pandemic arrives.

            And here is the perspective of all perspectives: the comparison between COVID-19 and The Great Influenza/Spanish Flu of 1918-19. The pandemic of a century ago killed approximately 50 times as many persons as the present one in only two years – perhaps as many as 100 million humans! Then as now, reporting was not accurate. The pandemic began during the First World War and the combatants purposely did not reveal the extent of the epidemic for political reasons. Then as now, misdiagnoses were common. Viruses had not yet been discovered in 1918 nor had antibiotics. The 20-40 year age group was severely affected and many children succumbed; COVID-19 has claimed very few young persons. No child below the age of 19 has died of the coronavirus in San Diego County at the time of this writing. And there was no vaccine in 1918.  

            Without sounding like a Pollyanna I feel that the trends and advances of this year will bring a much brighter picture in 2021. With that thought, I wish a most Healthy and Happy New Year to all those who have been following this blog.  

Carvings         December 15 2020

In the news

          The high cost of vitamin D deficiency

          A report published this week confirmed what several investigators have put forward since the onset of the COVID-19 pandemic: deficiency of vitamin D is a serious comorbidity. Belgian scientists report that persons with low levels of vitamin D admitted to the hospital for coronavirus infection had a 3.7-fold increase in the odds of dying.

            This report is not an outlier. There are now thousands of patients around the world in studies that show a clear correlation between vitamin D deficiency and severity of coronavirus infection.

            In this study men were more likely than women to be vitamin D deficient, probably because women, at higher risk of osteoporosis, often take vitamin D supplements. There was also a correlation with the severity of lung involvement: among men with the most severe lung disease 74 percent were vitamin-D deficient. In the words of one researcher, this news is “staggering”.

            Comorbidities such as obesity, coronary artery disease, diabetes and chronic lung disease cannot be reversed quickly but vitamin D deficiency can. Now that winter is here more than half the U.S. population cannot obtain this vitamin from sunlight exposure but anyone can take an inexpensive vitamin D supplement. At 1,000 or 2,000 units per day blood levels can increase quickly and there is zero risk of side effects at that dosage. We are in the midst of a surge in cases and deaths. There is no time to waste.

Lifestyle

Nutritional optical illusions                                                                                                            

            You’ve probably heard that by using a smaller dinner plate it will appear that there is more food there and you will eat less. The reverse is also true. If a plate is bigger and you fill it yourself you’ll put more on it – and you’ll probably clean your plate!

            Some ingenious researchers with a sense of humor went a little further. They offered Philadelphia moviegoers fresh popcorn in either a medium-sized bowl or a large one. (There is no such thing as a “small” popcorn bowl in a movie theater.) The large-bowl folks ate 45.3 percent more popcorn than those who had a medium-sized bowl. But the sadistic researchers went a step further. They did the same thing with stale popcorn – and the people with large bowls ate 33.6 percent more than the medium-bowl subjects.

            Even persons who should know better can fall into the trap. When a group of 85 nutrition experts were invited to an ice cream social, they were given either a small bowl with  a small scoop or a large bowl with a large scoop and were told to serve themselves. If they had a large bowl they took (and ate) 31 percent more ice cream. Those who used a large scoop gave themselves 14.5 percent more, whether they had a small or large bowl.          

            Take a look at your mealtime habits and ask yourself if you can make a few changes to take advantage of this nutritional illusion!

Pandemic Perspective #36   December 12, 2020

Superspreaders: today’s Typhoid Marys

            Mary Mallon was an unfortunate carrier of Salmonella typhi, the bacterium that causes typhoid fever. In the early 20th century she worked as a cook for several wealthy families in the New York City area where over two decades she infected 53 people, three of whom died of typhoid fever.

            More than a century later she would be outperformed – by a country mile – by COVID-19 superspreaders, persons who shed enormous numbers of virus particles. One of these was identified in the state of Washington where a singer infected 53 members of her choir, accomplishing in about two hours what it took Typhoid Mary to wreak over several years. A few other superspreaders have been identified in other parts of the world. They make for dramatic headlines but the illnesses that they ignite are few relative to the enormous number of cases, now exceeding 71 million throughout the world with more than 1 ½ million deaths.

            Superspreader events are more common and they have been observed in prior coronavirus pandemics, SARS and MERS. COVID-19 cases have erupted where large numbers of people congregate, especially when they mingle closely and ignore reasonable guidelines. These range from a church wedding to a swingers’ convention to a conference of biotechnology workers. The fallout from that gathering of scientists may have led at least indirectly, according to one study, to as many as 20,000 cases! Several events were initiated by persons who were in attendance in spite of having symptoms of COVID-19.

            As we enter the second year of the COVID-19 pandemic we all feel coronavirus fatigue and frustration but we need to face the reality that the current surge has not yet peaked. Some of the draconian restrictions imposed by politicians are ill-conceived and are not rooted in science – we should encourage, not restrict, outdoor activities and get our kids back in school. On the other hand we need to continue the practices that are effective, including avoiding crowded venues, maintaining social distancing outside the household and being tested if you are aware of having been exposed to a positive contact. Wearing an effective mask and wearing it properly does help, but only to a limited degree, and should not make us complacent about the other guidelines.

            Today’s dismal numbers will improve in the coming year as the most susceptible and the most at-risk persons receive a vaccine.

In the news

            EVALI is an acronym that likely does not affect a single reader of this blog but you might know someone who would benefit from this news item.

            Dr. Jeannie Huang of Rady Children’s Hospital penned an article in the San Diego Union-Tribune on November 27th, 2020 entitled Commentary: I’m a doctor in San Diego. Smoking and vaping put youth at risk for COVID-19.  EVALI (E-cigarette or Vaping use-Associated Lung Injury) arose from the recognition that lung damage is more prevalent among e-cigarette users than had been recognized when the fad began. Even before the onset of the COVID-19 pandemic the CDC reported that as of January 7, 2020 there was a total of 2558 hospitalized patients with vaping lung injury and 60 deaths.

            Tobacco use is also a risk factor in this pandemic. It wasn’t long before healthcare workers observed that smokers were more likely to be severely affected by SARS-CoV-2 and were more likely to die. That of course is in addition to the long-recognized fact that 50 percent of smokers will die of an illness caused directly by that habit!

            As we enter the flu season the risk is magnified: tobacco smokers are five times more likely to contract influenza than non-smokers. The e-cigarette picture is more complicated and the data connecting vaping to COVID-19 will take some time to sort out. There are literally thousands of different chemical ingredients in those little electronic sticks.

            If someone that you care about is a user of tobacco or a vaping device, consider forwarding this blog to them.

Lifestyle

            In the last Carvings I discussed intermittent fasting, actually time-limited fasting, eating nothing between about 7:00 p.m. and 7:00 a.m. My recommendation is a little more user-friendly than the original article, which described a 14-hour fast.

            Only a few days after that post an article in the Journal of the American Medical Association (JAMA), Effects of Time-Restricted Eating on Weight Loss and Other Metabolic Parameters in Women and Men with Overweight and Obesity appeared that contradicted the findings in the first article. The JAMA article, in turn, was skewered by reviewers for a variety of reasons, most of them logical and justified.

            This topic is going to be around for a while, generating lots of argument, and more studies will have to be done on many more patients, with better controls than were done in both studies. Here is the argument in support of my version of time-limited fasting, i.e., no food between 7 p.m. and 7 a.m.

            When vexing medical/biological issues arise I often revert to the fact that our bodies evolved over a couple of million years in conditions that were vastly different from today’s environment and especially our lifestyle. We can’t undo that in the few generations that brought us refined grains, refined sugars, processed foods and a dramatic decrease in physical activity.

            Consider: Until about 150,000 years ago humans lived in the equatorial region of Africa, where day and night are of equal duration. (In Kenya, each phase lasts about 12 hours and 6 minutes; with little variation throughout the year the sun rises at about 6:20 a.m. and sets at about 6:30 p.m.) Our Stone Age ancestors probably only ate during 12 hours of daylight. That is what our bodies have adapted to. It was only with the “advances” of civilization that we are able to enjoy dinner by candlelight in the evening and midnight snacks. By interrupting our circadian rhythm we brought on a myriad of  medical problems such as increased rates of obesity, cardiovascular disease and cancer. 

            The fasting period in the JAMA study lasted from 8 p.m. until noon the next day. The subjects ate three meals of their own choosing during the remaining eight-hour period that began at noon. They were all overweight or obese, including an unreported number, one or more, who were morbidly obese (BMI 43). I find it hard to believe that they ate fewer calories during those eight hours than the amount that made them fat. And although it’s somewhat controversial, skipping breakfast, in a number of studies, is likely to lead to weight gain, not weight loss. Further, eating a late meal on a regular basis also leads to weight gain.

            Having your final meal of the day no later than 7:00 p.m. will probably help you to sleep better, as reported in the first study. Eliminating late night snacks will improve your handling of blood sugar since there will be no spikes for at least 12 hours.

            At the end of the first study more than half of the participants said that they would continue to follow the fasting pattern. I wonder how many subjects in the JAMA study felt that way about their program.

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.