Many of us had to go grocery shopping for a variety of reasons over the last couple of weeks. We have been shocked by the crowd and empty shelves, but there was something even more shocking.
In looking more carefully, I also recognized that as a society, we are not prepared to fight a virus outbreak. From cart to cart, I saw boxes of soda, chips, candy bars, and a whole lot of frozen chicken wings. This picture epitomized the bandage-based approach we have as a country towards health and disease.
While the public health focus has been on isolation and sanitation to slow the spread of the virus, one thing we are not talking about is how our baseline health as a country makes us more susceptible to not only getting the virus but also succumbing to it. There is plenty of evidence and studies on the common flu and colds that have warned us that as a country, we are just not mentally or physically fit to fight a pandemic. The following are foundational cracks in our health and wellness that will make COVID-19 far more deadly.
We Have Failed to Address the Obesity Epidemic
Close to 50% of the U.S. population will suffer from obesity by 2030. Obesity has been well documented to increase one's risk of respiratory infections and more importantly increases the severity of those infections. During the 2009 H1N1 epidemic, obesity was discovered as a "novel" risk factor for severe cases requiring ICU care; 61% of individuals who died from H1N1 had a BMI >30. Follow-up studies showed that people who struggle with obesity have cellular defects in certain immune cells that contributed to higher mortality. South Korea has some of the lowest obesity rates in the world, and this could partially explain their lower COVID-19 mortality thus far.
We Are Too Sedentary
Only 35% of the adult population over the age of 65 is physically active. A 2013 study showed that for every 5% increase in physical inactivity the rate of influenza-related hospitalization goes up by 7%. While intense exercise has been known to suppress the immune system, moderate-intensity exercise not only improves immune function but also potentially reduces the risk of severity of respiratory viral infections. In a fascinating study, mice randomized to moderate exercise and then injected with H1N1 strain had one-third the mortality rate of those in a non-exercising control group (18% vs 56% mortality). In a randomized study in people over the age of 50, those randomized to an eight-week exercise program before the cold and flu season had 35% fewer cold and flu episodes and 47% fewer sick days.
We Don't Eat Enough Whole Fruit and Vegetables
Only 9.9% of Americans are meeting the CDC's vegetable intake standard. For every 5% increase in the number of Americans with low vegetable and fruit intake, our influenza hospitalization rises by 8%. In another study, older adults randomized to a diet high in vegetables for 16 weeks prior to receiving a vaccine had a greater antibody response to the vaccine, suggesting that vegetable intake enhances our immune response. In a 2010 study of over 1,000 women in Boston, those with the greatest fruit and vegetable intake had 39% fewer respiratory viral infections during pregnancy.
We Are Psychologically Stressed
In 2018, a third of Americans visited a doctor for stress-related conditions, and some surveys have reported that on any given day, over 50% of Americans are suffering from acute or chronic stress. In numerous studies, stress (chronic stress in particular) is associated with suppression of both our cellular and humoral systems. In 13 studies, psychological stress was demonstrated to be associated with decreased antibody response to the influenza vaccine. In a study I would never volunteer for, investigators measured stress via a series of questionnaires and then intentionally infected 394 people with five respiratory viruses. They found that rates of both respiratory infection and clinical colds after infection were increased in a dose-response manner with increases in the degree of baseline psychological stress. In another study, people who received an eight-week mindfulness meditation class right before cold and flu season had 33% fewer infections and had 66% fewer missed workdays.
Let Us Reconsider Preparedness for the Next Epidemic
Many people have voiced concern for the lack of preparedness by our healthcare system and government for the COVID-19 outbreak. The lack of quarantine protocols and diagnostic testing, as well as shortages in vital healthcare supplies, have put us in a tight spot that could be devastating. As a result, we have had to resort to a "shelter in place" panic response that is already leading to widespread economic disruption. South Korea has had a much better and less disruptive response for many reasons, but one overlooked factor is that they are a healthier population at baseline. After we emerge from this crisis, one key question we will need to grapple with is whether our healthcare system will wake up to address the obesity and lifestyle epidemics that are wreaking havoc at the foundations of our health and wellness.
Zeeshan Tayeb, MD
Adopted from Rami Bailony, MD