Obesity and chronic metabolic disease is killing COVID -19 patients: now is the time to eat real food, protect the NHS and save lives.

A healthcare system issue

Last week I inquired as to how a close friend of mine, a director of research and a senior clinical doctor in one of New York’s’ busiest ER departments, was coping amongst the coronavirus outbreak.

“A dire situation. Our already broken health care system is on the verge of collapse. Please pray for us” he replied.

Much has been reported in the media that, like the UK, the richest nation in the world been slow to react to the advice issued by the World Health Organisation on January 31st.

This has led to lack of vital Personal Protective Equipment, lockdown being ordered later than it should have, and lack of testing to determine true infection fatality rates and to implement rational mitigation and management (1) For COVID-19 prevention is not better than cure, prevention IS the cure, at least for the foreseeable future. It appears the disproportionate deaths of frontline staff without adequate protection has revealed close exposure to high viral load from patients, and may be tied to more severe illness.

In Britain, the primary reason for lockdown and social distancing has been to protect the NHS from being overwhelmed from a novel virus which is significantly more contagious and estimated to be several folds more deadly than the flu’s 0.1% infection mortality rate. (2)

Conversely, we must also deal with the adverse effects of such measures on population health and the economy. At what point does “house arrest” do more harm than good? (3)

But the elephant in the room is that the baseline general health in many western populations were already in a horrendous state to begin with. In the UK and USA more than 60% of adults are overweight or obese. How is this relevant to COVID-19?

Obesity, the real killer behind Covid

It is well known in the medical literature that excess body fat induces immune dysregulation and chronic inflammation which is directly linked to the cytokine storm that is responsible for Acute Respiratory Distress Syndrome seen in influenza and other respiratory viruses. (4)

For example, in 2009 61% of patients admitted to hospital in California that died from H1N1 Influenza A were obese, which was 2.2 times more than the prevalence of obesity within the state population. Multivariate analysis suggested obesity was a novel risk factor for mortality from the virus. (5) Furthermore, obese adults shed influenza A virus 42% longer than non-obese individuals suggesting an additional role in transmission. (6)

Data from the first 2204 patients admitted to 286 NHS ICU’s with COVID- 19 reveal that 72.7% of them were overweight or obese. (7)

Several years ago, a senior advisor personally expressed major concern to me about then-Mayor Boris Johnson. “I’m worried about his health Aseem. He’s significantly overweight and doesn’t look well.” This is despite the fact that Boris would regularly cycle to his office at City Hall. There’s no such thing as being fat and fit. (8)

We shouldn’t ignore the fact that 50-60% % of the 1.4 million NHS workforce are themselves overweight or obese too, not surprising when more than half of the British Diet is ultra-processed food (9) and three quarters of food purchased in hospitals is unhealthy. (10) South Korea which has one of the lowest prevalence of obesity in the world could in part explain it’s low mortality rate form the virus.

But more clinically important than BMI, tied to waist circumference is the prevalence of chronic metabolic disease which can affect many of “normal” weight. Furthermore, sarcopenic obesity may misclassify many elderly patients to having a normal BMI on hospital admission with COVID-19. Only 12.2 % of American adults are considered metabolically healthy, with less than a third of normal weight people also in this category (11). It’s likely the statistics are not dissimilar in the UK. In addition, normal weight metabolically unhealthy have a more than three-fold risk of all-cause mortality and cardiovascular events than those who are normal weight and metabolically healthy. There’s no such thing as a healthy weight, only a healthy person.

Diabetes and Metabolic syndrome accentuate the risk

A recent commentary In Nature states that “patients with type 2 diabetes and metabolic syndrome might have to up 10 times greater risk of death when they contract COVID-19” and has called for mandatory glucose and metabolic control of type 2 diabetes patients to improve outcomes. The authors also suggest making this a priority in ALL patients with COVID 19 will be beneficial. (12) It’s instructive to note that the disproportionate numbers of those from black and ethnic minority backgrounds succumbing to the virus may in part be explained by a significantly increased risk of chronic metabolic disease in these groups. For example, those of south Asian origin living in the UK type 2 diabetes is 2.5 -5 times more prevalent and three times more common in those of African-Caribbean descent in comparison to Caucasians.

Public Health England have said now is the best time to quit smoking, citing research from China concluding that smokers were 14 times more likely to get severe disease after contracting COVID-19. (13) But why not also ask the public to “quit ultra-processed food”? Observational studies have revealed a clear link between the consumption of such foods with obesity, metabolic disease and cancer. (14) A well-designed recent “landmark” RCT revealed a 2kg difference in weight within two weeks of participants consuming an ultra-processed versus a minimally processed diet plan. (15) Dietary changes are also known to rapidly and substantially reduce cardiovascular morbidity and mortality. (16)

25-50% of those with type 2 diabetes can significantly improve glycaemic control, blood pressure and send their condition into remission from a variety of interventions including a low refined carbohydrate diet (without needing to count calories) within weeks to months respectively. (17) (18) If this is not the time for Britain to reverse it’s epidemic of type 2 diabetes, which as a single condition has been the most costly to the NHS, then when is?

Healthcare systems were already overstretched before COVID-19 because of decades of maldistribution of resources due to “too much medicine” combined our collective failure to implement policy changes to address the root cause of diet related disease — the unavoidable junk food environment.

The government public health message enhanced by the media to stay at home, protect the NHS and save lives has been powerful and effective. Given the speed at which health markers for metabolic disease improve from dietary interventions, an equally strong if not more significant population health message should now be to “eat real food, protect the NHS and save lives.” Such implementation backed by policy changes may not just save hundreds and potentially thousands of lives around the world in the coming months but given the high likelihood of another international viral pandemic in the next decade a healthier population and a subsequently more manageable health service will be much better equipped to handle what would then be a smaller mortality peak on the next occasion. Hopefully if and when that occurs a lockdown will not be required.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4717890/pdf/an010207.pdf https://www.ncbi.nlm.nih.gov/pubmed/21208911 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6151083/ file:///C:/Users/User/AppData/Local/Microsoft/Windows/INetCache/IE/2H1KN739/ICNARC%20COVID-19%20report%202020-04-04.pdf.pdf https://academic.oup.com/eurheartj/article/39/17/1514/4937957 Rauber F, da Costa Louzada ML, Steele EM, Millett C, Monteiro CA, Levy RB. Ultra-Processed Food Consumption and Chronic Non-Communicable Diseases-Related Dietary Nutrient Profile in the UK (2008⁻2014). Nutrients. 2018;10(5):587.

https://www.theguardian.com/society/2019/may/22/food-bought-nhs-hospitals-unhealthy-audit-shows-crisps-sweets-cakes Araújo J, Cai J, Stevens J. Prevalence of Optimal Metabolic Health in American Adults: National Health and Nutrition Examination Survey 2009–2016. Metabolic Syndrome and Related Disorders, 2018; DOI: 10.1089/met.2018.0105 https://www.nature.com/articles/s41574-020-0353-9 https://www.gov.uk/government/news/smokers-at-greater-risk-of-severe-respiratory-disease-from-covid-19 https://archive.wphna.org/wp-content/uploads/2016/01/WN-2016-7-1-3-28-38-Monteiro-Cannon-Levy-et-al-NOVA.pdf Hall KD, Ayuketah A, Brychta R, et al. Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain: An Inpatient Randomized Controlled Trial of Ad Libitum Food Intake [published correction appears in Cell Metab. 2019 Jul 2;30(1):226]. Cell Metab. 2019;30(1):67–77.e3.

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