Metabolic Health, the CDC + America’s Underlying Comorbidities for COVID-19

We recently met functional medicine Registered Dietitian Brigid Titgemeier, MS, RDN, LD, IFNCP here in L.A. and, after a long conversation, realized just how in sync we were with her philosophies around health and nutrition. Brigid first found herself on the patient side of functional medicine after conventional medicine insisted on throwing only drugs her way. She quickly learned to use food as a powerful tool for her own healing and is now committed to helping others do the same. 

Brigid shares her in-depth insights on functional medicine and nutrition during this unique time in history with us here... 

In the last four months, the pandemic has taken a drastic toll on the world in ways that go beyond the surface of infection. The lives that have been taken and the health that has been altered by those infected is only one of the many devastating consequences. Other critical repercussions include massive unemployment rates, the delay of life saving surgeries for those with cancer and other chronic conditions, business closures, isolation, impaired mental health, increased concerns of suicide, loss of connection, incredible polarization and living with a persistent sense of fear (which in itself causes a slew of often overlooked health issues).

People describe the pre-corona world as the old way of living and the current state of the Covid-19 virus as “the new normal.” But accepting this tragic and vulnerable state as a new normal only adds an extra sense of gloom. From the start of the pandemic, health officials in the United States failed to release information regarding how to create health and support the immune system to improve resiliency–in other words, factors to protect the public amidst a pandemic.

Instead, today, the optimistic headlines for a return to normalcy involve an expedited vaccine. However, living in fear coupled with some form of a stay at home measure until one becomes available is not a way to live. It in fact may be more harmful than beneficial when you account for people’s mental health and the way in which ongoing restrictive measures limit physical activity, people’s ability to secure healthy foods and access preventative services.

The government has often failed to provide information about interventions that are available to the population today that could drastically improve an individual’s response to the virus if/when exposure occurs. Helpful interventions could include what is at the end of people’s forks, in addition to movement, stress reduction and sleep.

The National Recommendations
The advice and updates that Americans have relied on for COVID-19 come directly from the governing body of health information, the Centers for Disease Control and Prevention (CDC). At the time of publishing this article, the recommendations from the CDC include the following:

Wash your hands often
Avoid close contact
Cover your mouth and nose with a cloth face cover when around others
Cover coughs and sneezes
Clean and disinfect
Monitor your health

These guidelines are consistent with many standard public health recommendations, but they fail to acknowledge the unique convergence of this particular virus and the chronic disease terrain that persists in the United States. They fail to better understand how adverse outcomes from the pandemic are escalated by the alarmingly poor nutritional and metabolic health (heart health, blood sugar and body composition) of Americans.

The conventional healthcare system in the United States is structured to treat symptoms versus looking upstream, a functional medicine philosophy, which teaches practitioners to address root causes versus treating the symptoms of the root causes. The government and the CDC have taken a very different approach from looking upstream by failing to provide any education involving 1) How the immune system works and how to support it through lifestyle and 2) How to optimize immunological resilience and metabolic health with what you put at the end of your fork. While optimal nutrition is not a cure for coronavirus itself, it does support many of the underlying conditions and mechanisms that make the difference between mild and severe cases.

The research that exists demonstrates that the acute care virus is only one part of the story. The CDC has recognized that the baseline levels of chronic disease play a very significant role in disease severity of those infected. And it’s well known that chronic, inflammatory conditions are largely driven by a diet rich in ultra-processed foods and void of dietary fiber, micronutrients, phytonutrients and other foods that help improve metabolic health while synergistically strengthening immune health.

Despite this very clear correlation, the recommendations for the last several months have been for everyone to shelter in place, wear masks and hope for the best. This messaging fails to educate individuals on the vast number of behaviors that have scientifically been proven to improve not just the immune system but metabolic health as a whole.

Your immune system and your metabolic function require nutrients to do their jobs and can be suppressed or hijacked when too many inflammatory ingredients are added to the mix.

The State of Health Pre-COVID
Before diving into statistics directly tied to the pandemic, it’s helpful to paint a clear picture of what “health” in the United States looks like, both pre and during-COVID-19. Most people are surprised to learn that the metabolic health of the United States population is disturbingly low. Statistic show that:

+ Only 12.2% of adults in the United States are metabolically healthy, meaning they have a normal waist circumference, blood pressure, blood sugar, triglyceride levels, and HDL cholesterol levels and do not take any medication.
+ 6 in 10 adults in the United States have at least one chronic disease.
+ 4 in 10 adults in the United States have 2 or more chronic disease.
+ >100 million adults have pre-diabetes or diabetes.
+ 3 in 4 adults are overweight or obese.
+ Between 2013 and 2016, 121.5 million American adults had some form of cardiovascular disease.
+ In 2017, approximately 11 million deaths worldwide were attributable to poor dietary patterns that increased risk of disease.
+ In the United States, an estimated 678,000 deaths each year are due to poor nutrition and diet-related diseases, according to the Centers for Disease Control and Prevention.

Underlying Comorbidities for COVID-19
According to the CDC, a comorbidity is defined as having more than one disease or condition at the same time. Other names that can be used are coexisting or underlying health conditions.

The CDC reported that as of May 30, 2020 specific comorbidities or underlying health conditions are a significant risk factor for COVID-19. The most common underlying conditions reported were:

-Cardiovascular disease: 32%
-Diabetes: 30%
-Chronic lung disease: 18%

The CDC also reported that hospitalizations were 6 times higher and deaths were 12 times higher among those with reported underlying conditions compared with those with no known conditions.

This pattern of underlying health conditions was reported in China in March. That month, I published an article on Using Food as Medicine to Support your Immune Health During the Coronavirus Pandemic. In this article, I highlighted findings from a paper published in JAMA on March 13, 2020 that included 201 patients admitted to Wuhan Jinyintan Hospital in China with confirmed COVID-19. The study’s authors noted that approximately one-third of patients who were diagnosed with COVID-19 and required hospitalization for Acute Respiratory Disease Syndrome (ARDS) had comorbidities including hypertension, diabetes, and liver disease.

The same associations became increasingly apparent in the United States. One study published on April 22, 2020 in JAMA included more than 5,000 patients in New York City hospitals who contracted COVID-19 and required hospitalization due to complications.

The study highlighted that:

+ 88% of patients hospitalized had more than one comorbidity, with the most common being hypertension, diabetes, and obesity.
+ Approximately 6% of individuals who contracted COVID-19 and required hospitalization were free of any comorbidities.
+ 56.6% of those hospitalized had hypertension (high blood pressure).
+ 41.7% met the criteria for obesity (having a body mass index greater than or equal to 30, which is calculated by height and weight).
+ 33.8% had diabetes.

Another study published on June 17, 2020 assessed those who had the virus and required hospitalization compared to those who had the virus and did not require hospitalization. They found that hospitalized patients with COVID-19 were more likely to have Type 2 diabetes and obesity compared to those who were not hospitalized. The study findings included:

+ 55.9% of those who were hospitalized were categorized as obese compared to 33.4% of those who were non-hospitalized.

+ Among hospitalized patients, 36.8% had diabetes compared to 9.7% of non-hospitalized patients. 33.6% of the hospitalized diabetes cases were T2D and a very small percentage had Type 1 Diabetes (T1D).

In addition to the elderly population >65 years old and racial minority groups, those with poor metabolic health, are also a disproportionately higher risk of poor health outcomes from COVID-19. While there are some exceptions where a seemingly healthy 30 year old that is active and has healthy blood sugar/blood pressure contracts the virus and has poor outcomes, that is a very small minority.

Our greatest public health threat is the virus when plugged into the chronic disease terrain. This combination of factors creates the perfect storm, which can also be referred to as the cytokine storm.

The concern with making recommendations that are solely based on wearing masks and washing hands is that it doesn’t address a very important factor and may create a false sense of security. For many, addressing their own underlying health issues by taking care of their bodies with optimal food, movement, sleep and stress reduction can statistically create a high level of resiliency to the virus and may help in flattening the curve. Despite knowing this information, the CDC has yet to make recommendations telling people to eat their vegetables.

The CDC Acknowledges Metabolic Health in Face of the Pandemic
On June 25, 2020 the CDC updated its recommendations to acknowledge that “people of any age with certain underlying medical conditions are at an increased risk for severe illness from COVID-19”. This list includes:

Chronic kidney disease
COPD (chronic obstructive pulmonary disease)
Immunocompromised state (weakened immune system from solid organ transplant)
Obesity (body mass index [BMI] of 30 or higher)
Serious heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
Sickle cell disease
Type 2 diabetes mellitus

Following this acknowledgement, the CDC provided recommendations for this vulnerable group of individuals.

The CDC advises people with these chronic diseases or immunosuppression to limit interactions, take precautions when interacting with others, wear a cloth face covering and use alcoholic hand sanitizer. The website proceeds to list each disease state that increases risk or may increase risk of adverse outcomes and pairs it with “Actions to take.” The actions for every disease involve taking medication, ensuring they have enough medication stocked, and calling their healthcare provider if they have concerns about their condition.

Some examples of “actions” the CDC recommends for specific disease states include:

Diabetes:
Having type 2 diabetes increases your risk of severe illness from COVID-19. Based on what we know at this time, having type 1 or gestational diabetes may increase your risk of severe illness from COVID-19.

Actions to Take:
-Continue taking your diabetes pills and insulin as usual.
-Test your blood sugar and keep track of the results, as directed by your healthcare provider.
-Make sure that you have at least a 30-day supply of your diabetes medicines, including insulin.
-Follow your healthcare provider’s instructions if you are feeling ill as well as the sick day tips for people with diabetes.
-Call your healthcare provider if you have concerns about your condition or feel sick.
-If you don’t have a healthcare provider, contact your nearest community health center or health department.z

Serious Heart Conditions & Other Cardiovascular and Cerebrovascular Diseases:
Having any of the following serious heart conditions increases your risk of severe illness from COVID-19:
Heart failure, Coronary artery disease, Congenital heart disease, Cardiomyopathies, & Pulmonary hypertension
Having other cardiovascular or cerebrovascular disease, such as hypertension (high blood pressure) or stroke, may increase your risk of severe illness from COVID-19.

Actions To Take:
-Take your medicines exactly as prescribed and follow your healthcare provider’s recommendations for diet and exercise while maintaining social distancing precautions.
-Continue angiotensin converting enzyme inhibitors (ACE-I) or angiotensin-II receptor blockers (ARB) as prescribed by your healthcare provider for indications such as heart failure or high blood pressure.
-Make sure that you have at least a 30-day supply of your heart disease medicines, including high cholesterol and high blood pressure medicines.
-Call your healthcare provider if you have concerns about your condition or feel sick.
-If you don’t have a healthcare provider, contact your nearest community health center external icon or health department.
-Do not delay life-saving treatment or emergency care.

Obesity
Having obesity, defined as a body mass index (BMI) of 30 or above, increases your risk of severe illness from COVID-19.

Actions to Take:
-Take your medicines for any underlying health conditions exactly as prescribed.
-Follow your healthcare provider’s recommendations for nutrition and physical activity, while maintaining social distancing precautions.
-Call your healthcare provider if you have concerns or feel sick.
-If you don’t have a healthcare provider, contact your nearest community health center external icon or health department.

The governing body of health, the CDC, the authority that Americans are encouraged to trust as the source of health recommendations, acknowledge the role that chronic disease plays in the pandemic but does not provide health-seeking recommendations during these tumultuous times. The ‘Actions to Take’ are written in a language presuming diagnosis of obesity or Type 2 Diabetes is a static state that is unable to be reversed. This treatment based approach does not look upstream to ask the question that functional medicine always starts with: why do you have diabetes? Why do you have hypertension? Statistically, the answer to these questions, for the majority of Americans is rooted in  diet.

But here is the good news: the message does not have to be surrounded by doom and fear. There are other interventions that you can incorporate into your life beyond wearing a mask and washing your hands -- which are important also.

There is ample research demonstrating the indisputable role of nutrition and lifestyle on improving underlying comorbidities and metabolic function.

If you find yourself at a higher risk due to having an underlying comorbidity or if you want to create more resiliency, choose a few goals from the list below that may support you:

+ Actively prioritize your health.
+ Provide the immune system with nutrients that it needs
+ Get your vitamin D levels checked and take a supplement if you are low

+ Incorporate 2-3 cups of vegetables into your diet daily to increase fiber, vitamin C and antioxidants
+ Try to eat at least 3 different colors with each of your meals
+ Create daily mantras that establish a positive mindset and decrease fear of the unknown
+ Spend 15-20 minutes or more per day outside to help support your immune system and increase exposure to sunshine
+ Drink half of your body weight in fluid ounces of clean water daily
+ Reduce your intake of foods that create an inflammatory response -- fried food, fast food and highly processed foods
+ Remove soda, liquid sugar and added sugars from your diet to help lower blood sugar response
+ Consider fasting overnight for 8-12 hours at a time to help with blood sugar and blood pressure levels.
+ Move your body for at least 30 minutes per day, 5 days per week
+ Incorporate stress reducing practices such as taking deep breaths, meditation or yoga
+ Create a healthy evening routine that is conducive to optimal sleep

As someone with a Master’s of Science in Public Health Nutrition, I am very aware of some of the limitations that exist in our current society that make it uniquely challenging for those of lower socioeconomic status to access quality foods, but the health disparities are not a reason to give up and settle for lower standards. That is why 10 of the 15 recommendations listed above are 100% free.

There’s much more work to be done on a federal level with improving the food supply and decreasing influence from the food industry, but in the meantime, people can use Supplemental Nutrition Assistance Program (SNAP) dollars to purchase whole foods like apples, carrots, extra virgin olive oil, avocado, almonds and other whole food ingredients.

Knowing the Numbers
It’s important to have an accurate idea of your risk of infection and death, if in fact you were to contract the virus. As of July, 2020, the infection rates have started to increase but the total number of deaths in the United States have gone down. The CDC has yet to report a case fatality rate but based on data reported by the CDC, the ‘best estimate’ of case fatality rate for individuals showing symptoms is 0.4%. The total fatality rate, including asymptomatic carriers is expected to be slightly lower than that. The CDC also stated that 8 out of 10 deaths have occurred in those 65 years and older, which means the death rate is extremely low in individuals younger than 65 years old.

According to news outlets, the CDC Director, Robert Redfield told journalists on June 25, 2020 that the number of cases may be up to 10 times higher than the estimated rate. If that is the case and the number of infections is that much higher, that means the death rate may be substantially lower.

This by no means indicates that people should be irresponsible when it comes to the pandemic. Examples of this would include going out of your house when you feel sick, not washing your hands, going to large gatherings, etc., but it does highlight the importance of not being paralyzed by fear. Unintended consequences of being overly worried and fearful can include anxiety, depression, insomnia, weight gain, extreme social isolation and more. Continue to be extra cautious, especially if you are above the age of 65, immunocompromised, or have a chronic disease that puts you at a higher risk of adverse outcomes.

Regardless of who you are, work on improving your nutrition and physical activity, protect those who are at a greater risk, lower your stress response, improve your vitamin D levels, and try to avoid spending every second that you are in the grocery store stressing about the idea of contracting the virus.

A Message of Empowerment
You never know what you are training for in life, but the goal in choosing healthy behaviors daily is to be ready for anything. The current pandemic has exposed the vulnerable state of our healthcare system and the alarmingly low percentage of the population that is metabolically healthy. This information has always been accessible to us, but the pandemic has created more urgency to improve these statistics. Covid-19 has created a more immediate risk for those with long-term chronic diseases.

There is no greater gift that you can be given than the gift of health. In this one life we are given, let's be as intentional as we can to care of this gift. It is never too late to prioritize. As a functional medicine dietitian that has worked with over 4,000 patients, using food interventions to help improve disease, I regularly see disease improvement and reversal after varying lengths of time.

The Chalkboard Mag and its materials are not intended to treat, diagnose, cure or prevent any disease. All material on The Chalkboard Mag is provided for educational purposes only. Always seek the advice of your physician or another qualified healthcare provider for any questions you have regarding a medical condition, and before undertaking any diet, exercise or other health-related programs.

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