"Modifiable Risk Factors and Comorbidities for Severe COVID-19 Infection"
The severity of COVID-19 varies widely based on pre-existing conditions.
Those with high blood pressure are at twice the odds of suffering
a severe course, and those with cardiovascular disease
3 times the odds. What's more,
those with either condition are about 4 times more likely to end up in the ICU.
Those with COPD—chronic obstructive pulmonary diseases like emphysema—
appear to be at the highest risk with 6 times the odds of a severe course
for COVID-19, and nearly 18 times the odds of admission
to an intensive care unit.
We know that exposure to air pollution can increase susceptibility
to respiratory viral infections, and that may be the case with COVID-19 as well,
as higher pollutant levels appeared to be correlated with pandemic deaths.
But just as air pollution may influence COVID-19, COVID-19 may be
influencing air pollution. Check out this satellite data from NASA.
This is nitrogen dioxide pollutant levels before the pandemic, then after lockdown.
Here's what ground zero, Wuhan province, looked like
at around this same time last year, and then post-pandemic.
Ready for some irony? The decrease in air pollution
following the quarantine is so great that the COVID-19 pandemic
may paradoxically have decreased the total number of deaths
by drastically decreasing the number of fatalities due to air pollution,
averting as many as 30,000 deaths a month in China.
In other words, the air quality in China was so bad that COVID-19
may have ended up saving lives— like a thousand lives a day!
A history of smoking is a risk factor for disease progression, though
surprisingly, active smoking may or may not be. This seeming paradox
may provide a clue as to why those with high blood pressure appear
to be at higher risk. It's easy to imagine why those with
heart disease are at higher risk of crashing from COVID-19.
Even without direct heart damage,
lung infections can put a tremendous strain on the heart.
Up to 30% of patients hospitalized for regular pneumonia
develop cardiovascular complications.
About one in 35 suffer cardiac arrest, and those who don't
are still at 4 times higher risk of a heart attack or stroke
within the first 30 days after being released from the hospital.
OK, but why is just having high blood pressure a COVID-19 severity risk factor?
Under certain circumstances, those hospitalized for regular pneumonia
with hypertension may do even better. Investigators speculated this may be
due to the anti-inflammatory effects of a common class of high blood pressure
drugs called ACE inhibitors, like lisinopril, for which there are more than
a 100 million prescriptions dispensed annually in the United States alone.
Super common drugs.
And indeed, people on those drugs not only appear to be less likely
to die of pneumonia, but they seem less likely to even get pneumonia
in the first place. Ironically, this same reason why those with hypertension
may be protected from regular pneumonia may also be the reason
why those with hypertension are at greater risk from COVID-19.
ACE inhibitor drugs may be anti- inflammatory, but they may also
upregulate the expression of ACE2, which, as you may remember,
is the enzyme the COVID-19 virus spike protein latches onto
in our lungs to infect our cells and spread.
So perhaps the reason those with hypertension seem to do
worse is that so many of them are on this class of drugs,
which may be making them more susceptible to viral attack.
ACE2 expression is increased in some of these comorbid conditions,
but the drug connection has yet to be verified.
So more evidence is urgently needed to confirm the relation,
if any, between these high blood pressure drugs and COVID-19.
In the meanwhile, here's a flow chart that can help guide your doctor.
Should we be holding all the ACEs? Well, certainly, those on these drugs
for heart failure or severe or uncontrolled hypertension
should continue on these drugs. When ICUs are overwhelmed,
definitely not the time to have a stroke. However the majority
of people taking these drugs do so for treating well-managed
mild hypertension, and for these patients,
physicians may want to consider temporarily discontinuing them
for those at high risk of contracting COVID-19 until we know more.
As always, you should never just change or stop taking medications
on your own without guidance from your prescribing practitioner.
Those of you who follow me on social media know that early on
I recommended that people consider not taking ibuprofen unnecessarily,
as it's another drug thought to boost ACE2 expression. While the concern
again remains theoretical, no drug is completely benign.
NSAID drugs like ibuprofen cause intestinal lining damage in as many
as 80% of users, for example. So, no drug should be taken unnecessarily.
Furthermore, NSAID use, ibuprofen use, is strongly advised against
in lower respiratory tract infections, as it's been associated
with higher complication rates in both children and adults with pneumonia.
In fact, fever may actually be beneficial in COVID-19
and probably shouldn't be routinely treated by any means.
If you have a fever, cool compresses to the face can
make you feel better without dousing your internal high temperature
which may be helping fight off the infection.
Having said all that, those prescribed low dose aspirin
for cardiovascular disease should continue to take it.
To bring this full circle, the ACE2 connection may also
offer some insight into the inconsistent findings between
current and past smokers. Nicotine may downregulate ACE2.
So while it's always a good idea to quit smoking, this may explain
why active smokers may or may not necessarily be
at significantly higher risk of COVID-19 progression.
Reversing your type 2 diabetes may help, as those with diabetes
may suffer a more severe course.
The same was true for past deadly coronavirus outbreaks, SARS,
and MERS, the Middle East Respiratory Syndrome.
In this regard the virus has relentlessly highlighted our global Achilles heel
of metabolic dysfunction, but also points to a prime opportunity to fight back.
That fight, however, is not going to be won only with Clorox, Purell, masks
or anti-inflammatory drugs. The fight will only be won through a serious
commitment to improving everyone's foundational metabolic health,
starting with the lowest hanging evidence-based fruit: dietary
and lifestyle interventions. In other words, consuming fresh, fiber rich
whole foods could serve to mitigate some of the overwhelming
pro-inflammatory immune response that appears to be compounded
in patients with COVID-19 who have diabetes and obesity, and must be
a central focus included in any clinical recommendations made to patients
or healthcare systems during this pandemic.
Excess body fat alone seems to be a risk factor, independent of diabetes.
Those with severe obesity— weighing more than 215 pounds
at the average American's height of 5' 6"—have 7 times the odds
of ending up on a ventilator. But even just being overweight puts you at risk.
Those with a body mass index (BMI) of 28 or more—about 175 pounds
at the average height—appear to be at nearly 6 times the odds
of suffering a severe COVID-19 course.
So BMI of 28 or more puts you at more than 5 times the risk,
and the average BMI in the United States is over 29.
So were not talking about obese. Just being overweight, skinnier
in fact, than the average American, may put you at significantly higher risk.
The excess risk from the excess body fat may arise
from greater systemic inflammation, fat covering the heart itself,
or the restriction of breathing caused by excessive fatty tissue
in the upper body. Even without taking weight into account, though,
sadly most American adults over the age of 50 suffer from
a co-morbidity that may put them at risk such as heart disease,
lung disease, diabetes, high blood pressure or cancer.
I know I have my infectious diseases hat on right now
rather than my lifestyle medicine hat, but I can't allow it to pass
without comment that the major comorbid conditions for
COVID-19 severity and death—
obesity, high blood pressure, type 2 diabetes, and heart disease—
all can be controlled or even reversed
with a healthy enough diet centered around whole plant foods.
Thus, in terms of the impact of nutrition, now more than ever
wider access to healthy foods should be a top priority
and individuals should be mindful of healthy eating habits to reduce
susceptibility to and long-term complications from COVID-19.
Not all risk factors are modifiable though.
Advanced age is also a key risk factor for COVID-19 progression and death.
Although the disease has afflicted newborns only a few days old
through seniors in their 90s, most patients—around 90%
in one large case series— are between 30 and 79.
The severity of disease, however, disproportionately affects
older individuals. In China, the average age of those requiring intensive care
was 62, compared to the non-ICU cases, which had an average age of 46.
In the United States, even those 65 and older without underlying conditions
or other risk factors appear to be hospitalized or end up in the ICU
at approximately 3 times the rate of those 19 through 64.
Though the media has capitalized on stories of young,
healthy individuals suffering severe or even fatal outcomes,
people under 65 without known underlying, predisposing
conditions may only account for about 1% of COVID-19 deaths.
South Korea has some of the best data because they did
such widespread testing. As you can see, of confirmed cases
only about 1 in a thousand died in their 30s and 40s.
So if you're healthy in your 30s and 40s, only about
1 in a thousand chance of dying,
but for those in their 50s that rises to closer to 1 in 200.
Those in their 60s, about 1 in 50 die.
Those in their 70s, it's closer to 1 in 14,
and in their 80s nearly 1 in 5 lost their lives to COVID-19.
Though the relative lack of testing makes U.S. data less reliable,
based on the first few thousands of American cases
these age-related death risks are similar, as you can see.
Note those are percentages.
Lots more younger people are getting infected, so if you look
at the absolute numbers, you can see a big chunk of people
are getting hospitalized and sent to the ICU in their 20s, 30s, 40s, and 50s.
Lots of younger and middle-aged folks are suffering significant illness,
but the vulnerability of our seniors to the pandemic was exemplified
by ground zero of the first major U.S. outbreak,
a nursing home in Washington State. Of the home's 130 or so residents,
101 became infected and a third lost their lives.