Dr. Dariush Mozaffarian, Dean of the Friedman School of Nutrition Science & Policy at Tufts University summarized some of the challenges and hard truths in these two statements over twitter: @Dmozaffarian

As our nation prepares for the next phase of the coronavirus pandemic, we deliberate over  a road map outlined by the former commissioner of the Food and Drug Administration, Dr. Scott Gottlieb, who wrote National coronavirus response: A road map to reopening.  We are now beginning to have discussions about transitioning from Phase I- Slow the Spread to State-by-State Reopening to Phase II.

We can see in the distance Phase III:  Establish Immune Protection and Lift Physical Distancing and hopefully Phase IV,  Rebuild Our Readiness for the Next Pandemic.

Whether you are in healthcare, government or the military in a time of crisis, the one consistent rule is that it is always best to tell the truth.

Limit Sugar Consumption?

Just this week the World Health Organization launched a stay healthy at home campaign, urging adults to limit their sugar consumption to less than six teaspoons a day. No doubt the amount should be even less for children. To give you a frame of reference for six teaspoons looks like, one small carton of chocolate milk that we freely serve to our children at schools has more than 6 teaspoons of sugar.

Here in the Mountain State of West Virginia as well as the world over we love to indulge and take comfort in highly processed foods loaded with sugar and refined carbohydrates. Maybe with your gym closed, more stress and time at home, less walking with stay-at-home orders, you or a family member have already succumbed to the ten-pound “COVID cushion.”

The U.S. Centers for Disease Control estimates that about 75 percent of the over two trillion dollars we spend on health care each year goes to treat chronic illness, much of which can be mitigated by improved diet and lifestyle choices as well as policies that supports these better choices.

The reality is that we are partially responsible for our fragility to an attack such as the coronavirus. Now, we are hoping that our states and our nation can have a strong enough healthcare system to pull us out of this pandemic.  But the current crisis reveals how truly vulnerable we are.

COVID and Comobidity- A Deadly Combination?

Comorbidity means that a patient had at least one other disease in addition to COVID-19. This novel coronavirus emerged in China over five months ago, and we are rapidly discovering how the virus attacks the human body: who it kills and how.  U.S. experts attributed the rapid spread and high mortality rates in China to air pollution, higher smoking rates, and advanced age.  But a different set of risk factors are emerging as we look retrospectively at the data from China as well as current data in the United States, with obesity being a leading comorbidity.

Just this week, three new studies (here and here and here )from separate teams in New York City point to obesity as a major risk factor for COVID-19 hospitalizations and ICU admissions .

In the first study, on more than 3,600 people who tested positive for COVID-19, more than 20% had a BMI of 30-34 (obese Class 1) and more than 15% had a BMI > 35 (obese Class 2 or greater) . The rate of all obesity in New York City hovers around 28% . My state is north of 40%. Importantly though the rates of intensive care admissions were double for those with a BMI over 30 and nearly four times for those with a BMI greater than 35.

In the second New York city study looking at over 4000 COVID-19 patients found that apart from being over 75 years of age, obesity was the most significant risk factor predicting hospitalization and the need for critical care.

The third one looked at records from 5,700 people with COVID-19 who had been admitted to hospitals in the New York City. 94% of them had at least one comorbidity. The most common were hypertension, obesity and diabetes .

This week’s report from the Centers of Disease Control and Prevention (CDC), covering more than a dozen states and thousands of patients reported hospitalization and complication and death rates were highest amongst those who were ≥65 years of age and those with underlying medical conditions. “Approximately 90% of hospitalized patients identified through COVID-NET had one or more underlying conditions, the most common being obesity, hypertension, chronic lung disease, diabetes mellitus, and cardiovascular disease”  stated the report.

In a recent meta-analysis of the most current data confirms the greatly increased risk with the usual co-morbidities we see daily in our practices and community .  From the conclusion: Hypertension, diabetes, COPD, cardiovascular disease, and cerebrovascular disease are major risk factors for patients with COVID-19.

While we already knew that elderly people were at greater risk for  COVID-19–associated hospitalization, the degree to which underlying medical conditions contribute to increased risk is astonishing. The lesson here is that we should be focusing on everything possible to reduce these rates of diet-related diseases.

Almost all of those comorbidities, including hypertension, diabetes, coronary artery disease, and obesity are linked to the common root cause of insulin resistance. According to one recent estimate, 88% of Americans having markers of insulin resistance, the root cause of the so-called “metabolic diseases,” that include obesity, Type 2 diabetes and cardiovascular disease.  This means only 12% of our population is well. Witnessing how these diseases are increasingly implicated in poor outcomes for coronavirus victims, we need to take insulin resistance far more seriously.

What are the markers of a metabolically healthy individual?  See if you pass the test

  1. Waist Circumference: take 2 times your waist at the belly button- it should be less than your height
  2. Systolic Blood Pressure: < 120 mmHG
  3. Diastolic Blood Pressure: < 80 mmHG
  4. Fasting Glucose: < 100 mg/dL
  5. HbA1c: < 5.7%
  6. Triglycerides: 150 mg/dL
  7. HDL cholesterol: ≥40 mg/dL in men and ≥ 50 mg/dl in women

Image courtesy of Dr Phil Maffetone

What Is Happening in Communities of Color?

But what about New Orleans and their Mardi Gras celebrations in late February?  Why are so many dying especially African Americans?. Louisiana is a perennial top-five state in obesity with a 37 percent obesity rate.  According to Reuters News and a recent report out of New Orleans, “Some 97% of those killed by COVID-19 in Louisiana had a pre-existing condition, according to the state health department. Diabetes was seen in 40% of the deaths, obesity in 25%, chronic kidney disease in 23% and cardiac problems in 21%.That includes 60 percent with hypertension, 38 percent with diabetes and 22 percent with morbid obesity. Many of the victims suffered more than one of those conditions.”

The comorbidity data might be clue to some of the racial disparities we are witnessing in COVID-19 deaths. The CDC’s report this week revealed that 30 percent of COVID-19 patients are African American, even though African Americans make up only about 13 percent of the population of the United States.  Regardless of  the city or state, be it at New York, New Orleans, Chicago, Detroit, or California, the data is consistent. Black Louisianans account for 59 percent of the state’s COVID deaths, but make up just 33 percent of its population. In Chicago, African Americans make up 29 percent of the population but have suffered 70 percent of deaths.

We have much to study and learn here. African Americans live in historically underserved communities and are less likely to have the supports to lead a healthy lifestyle. Their greater disease rates are rooted in their social, economic, physical and even psychological factors such as chronic stress. Native Americans are also extremely vulnerable and may be in the next wave as COVID- 19 finds its way into more remote areas.

Even in our state’s capital Charleston the preliminary data on minorities and more severe infection is troublesome . One factor that whites and blacks, rich and poor all have in common, however, is accurate, evidence-based advice on the lifestyle factors that can reverse these diseases.

Possible Mechanisms for Worse COVID-19 Outcomes?

Based on the preliminary data that has been emerging, the following are some possible ways that obesity and other chronic diseases might contribute to worse COVID-19 outcomes.

The role of ACE- 2 receptor

A virus works by gaining access to the cells of its host and then hijacking a receptor on the cell. In the case of SARS-CoV-2,  access is obtained via the ACE-2 receptor, which is why the virus gains access to readily through the lungs and small intestine—because these tissues have ample amounts of ACE-2 receptors. The vascular system also abounds in these receptors, and they are upregulated in conditions such as hypertension. We are witnessing the lungs, GI system, vascular system, and heart (which is a big vascular organ) as vulnerable to the attack.  Studies in this area are still in their infancy but at there is some logic to the connections.

Endocrine and Metabolic Link

A recent paper, Endocrine and metabolic link to coronavirus infection, discusses the negative impact of the virus on the pancreas, indicating that the Coronavirus might exacerbate, or even cause, diabetes by seriously damaging pancreatic islets where insulin is formed. Diabetes combined with SARS-CoV-2 pneumonia may in fact form a vicious circle, with impaired beta cell function combined with glucose dysregulation amplifying the negative effects of the virus.

We are witnessing now unusual cases of clotting and strokes.  This 2006 paper entitled Hyperglycemia Stimulates Coagulation, Whereas Hyperinsulinemia Impairs Fibrinolysis in Healthy Humans.  In a bit of revisionist history the paper states: The differential effects of hyperglycemia and hyperinsulinemia suggest that patients with hyperglycemia due to insulin resistance are especially susceptible to thrombotic events by a concurrent insulin-driven impairment of fibrinolysis and a glucose-driven activation of coagulation. 

More revisionist history from a 1972 paper showed hyperglycemia negatively affects white blood cell defense against infection. High glucose impairs these cells in the innate immune response to invading organisms.

Researchers and clinicians will need to sort out whether the COVID related cases are associated more with the patients in poor metabolic health.

The Immune Dysregulation

A basic concept of immunology that many do not understand is the innate (first responder) immune system and the more delayed adaptive (second responders providing immunity).  Both of these arms reflect your overall health. It has been known for some time that the immune system’s multiple arms are negatively impacted by obesity and metabolic syndrome.  In 2017, Anderson described this well in her article Impact of Obesity and Metabolic Syndrome on Immunity. In 2019 Zhou et al added to the discourse in their paper Longitudinal multi-omics of host–microbe dynamics in prediabetes

From the paper:

first, healthy profiles are distinct among individuals while displaying diverse patterns of intra- and/or inter-personal variability. Second, extensive host and microbial changes occur during respiratory viral infections and immunization, and immunization triggers potentially protective responses that are distinct from responses to respiratory viral infections.

Moreover, during respiratory viral infections, insulin-resistant participants respond differently than insulin-sensitive participants. Third, global co-association analyses among the thousands of profiled molecules reveal specific host–microbe interactions that differ between insulin-resistant and insulin-sensitive individuals.

……Our study reveals insights into pathways and responses that differ between glucose-dysregulated and healthy individuals during health and disease 

The often discussed cytokine storm rages more severe in the patients with diabetes. Moreover glycation in itself suppresses immune function in times of immune challenge.

How to Protect Yourself/Your Patients Against COVID-19

Another future direction might be the role of cholesterol and it this time we are way too early to draw anything conclusive from theory so this section food for thought. Almost all of my patients who have hypertension, diabetes, and heart disease are told that they should lower their intake of saturated fat, lower their cholesterol, and take a cholesterol lowering medication. Recently, the World Health Organization guidance for COVID includes advice to reduce intake of saturated-fat to nearly zero. The focus on cholesterol-lowering may have counter-productive effects in fighting the virus, however.

Studies show the viral antibodies our immune systems create can partner with cholesterol molecules to become more robust virus killers. Studies on sepsis reflect less mortality with higher HDL -cholesterol as well as association of low LDL-cholesterol with worsened sepsis . Data from China are showing how those with the lowest cholesterol are having poorer outcomes- although this phenomenon could well be due to the fact that cholesterol tends to drop when someone is in the stages of acute illness

Vitamin D which is involved in cholesterol synthesis pathways also may have a protective role when out stores are sufficient. Of course everything has trade offs so I’m not suggesting you stop your cholesterol medication but something to consider if your indication for taking is soft.  A coronary artery calcium score is a surer way to determine your heart disease risk.   Now might be a good time to find out. Assessing your vitamin D status is inexpensive and actionable so consider a level and supplement if you are below 30ng/ml.

What Can We Learn From The Front Line?

Critical care doctors from the world over are observing and researching the connections. Through the lens of an internist in New York:

Every critical care specialist attending COVID-19 patients in the intensive care unit where I have been filling in as an intensive care physician for the past two weeks makes the same observation: Our patients seem almost universally obese, while most ill but stable patients elsewhere in the hospital have lower body masses. Critical care doctors in other parts of the country, as well as my colleagues in Europe, report seeing the same thing.  

The article details what we have learned historically from other viral pandemics as well as the effects of diabetes and obesity on individual immune systems. From the article: All of this suggests that health care needs to be augmented not just with more screening and treatments but with improved health access and greater health literacy.

Should my own profession shoulder some of the blame for the obesity pandemic that is exacerbating the COVID pandemic?  We have often blamed the victim for having obesity but obesity and excessive body fat is also a global pandemic affecting up to 80% of the world’s population.  My good friend and colleague in sports science Dr. Phil Maffetone shares some amazing data in this paper just published this week in entitled The Perfect Storm: COVID-19 Pandemic Meets Overfat Pandemic.

In our current scenario where it is difficult to predict  the course of the virus, the only true source of control you have is you. The best thing anyone can do is to strengthen his or her’s resistance to the coronavirus. As Dr. Mattefone writes, “Perhaps an important global lesson already learned during the COVID-19 pandemic is that it is easier to prevent viral infections than to treat them. Individuals and governments need not only practice current mitigation strategies such as safe distancing, but must focus on overall health.  People can control much when it comes to their health. The prevention of infections through a healthy immune system — including maintaining proper levels of body fat — is strongly associated with a healthy lifestyle.

Truly healthy people rarely need medication for chronic lifestyle related conditions. So instead of merely managing your conditions make it your goal to make them go away since exposure to and risk of  COVID 19 will not be like a blizzard (hitting hard and passing over quickly), but rather a long hard winter.

From the article The perfect storm: COVID-19 pandemic meets overfat pandemic; Maffetone PB, Laursen PB

Processed Food a Pathogen?

The food industry also capitalizes on stress and the impulse to eat and the news reports the consumption of processed food and junk food has been increasing over the last month. The New York Times shares an insightful piece  ‘I Just Need the Comfort’: Processed Foods Make a Pandemic Comeback. When the unhealthy choices are the easy choices how can we expect families to remain healthy and restore health.

And now to assess your physical activity? It is unfortunate that so many gyms are closed, and many people feel uncomfortable doing their usual exercise outside.  Multiple media reports from fitness trackers show a national decline in activity.  We know that physical activity is an immune booster and walking and that running outside is powerful in so many ways.

And for comfort in idle time the consumption of alcohol has in turn increased. Perhaps not a good idea as alcohol suppresses the immune system.  Just as it may slow your senses and reflexes it does the same thing to your immune system.

For Safer Re-Entry – Eat Real Food?

Just this week the much touted “COVID cocktail”  hydroxychloroquine and antibiotic combination came up bust and could potentially cause harm.  Early data  resdemiver which was another big hope for Big Pharma is not showing hope either . CDC director Redfeld in being truthful also warns this all might get worse as we reopen society. NPR summarized the reopening projections from the data center at The University of Washington and our state might be an early entry. The models and projections on what all this will look like going forward has lots of variables and the uncertainties are outlined in this piece by Dr Peter Attia.

Despite all of this gloom, I have been marveled at the individual and national response to the crisis especially amongst my healthcare colleagues. We have also taken personal responsibility in distancing, masking, and applying personal hygiene. Together we can slow the obesity and diabetes pandemic and flatten and reverse this curve as long as we are armed with knowledge and guidance from our health authorities.

Friend and colleague Dr Aseem Malhoutra from the UK in his article COVID 19 and the elephant in the room gives the simple solution: Obesity and chronic metabolic disease is killing COVID -19 patients: now is the time to eat real food, protect the NHS and save lives

Follow your grandmother’s advice and eat the nutrient dense foods such as seafood, eggs, and meats and not rely on failed thinking from the 80’s. Eat for low and stable blood sugar and if you have diabetes consider a CGM (continuous glucose monitor).

I hope a new world where we all take personal responsibility of our health and those around us emerges We can and must reduce our risk in the ongoing pandemic and in ones to come.  The ongoing obesity, diabetes, and metabolic disease pandemics remain in the background exerting their negative effects.  It’s time to take back our health!

Sidebar how to boost your host immune response

  1. Sleep- shorting yourself of sleep can negatively impact your immune system, so get adequate rest. It’s ok to be a bit less productive .
  2. Stress- no doubt you and others are under stress now. the field of “psychoneuroimmunology” has shown that state of mind matters. So find some time and activities for restoration
  3. Activity- movement matters. so make sure to get some daily, but not too much.  A nice article from my college Alma Mater UVA  here.
  4. Food- To reduce hyperinsulemia and insulin resistance which leads to metabolic disease choose nutrient dense foods with healthy fat and protein as the foundation. Our clinical guide here.

Mark Cucuzzella MD, FAAFP
Professor Family Medicine
West Virginia University School of Medicine

WVU Center for Diabetes and Metabolic Health


Dr. Mark is an author, avid runner, race director for Freedoms Run series, owns a small community running store (which is trying to survive COVID), and advocate for prevention and healthy living.  www.drmarksdesk.com