Beware of the Covesity Pandemic

Background

Covesity is a slang term found in the Urban dictionary here that references the common weight gain arising from our pandemic lifestyle habits.  I’m going to elevate this term from urban slang to a public health crisis that refers to the mechanism by which obesity, particularly abdominal obesity, might be putting you at immediate risk for a severe COVID-19 infection or death.

I’m not using this as a clever way to motivate you to do something you’ve needed to do for years, which is lose a few inches around the waist.  I’m sounding an alarm bell based on known science and global anecdotal experience coming from frontline doctors who are treating seriously ill COVID-19 patients, and identifying common risks in young individuals who are succumbing to an insidious version of this disease.  I am shifting my paradigm based on this research and viewing Covid-19 as not purely an infectious disease, but a lifestyle related disease.

Your current and future lifestyle habits may be the single greatest predictor of whether you survive Covid-19, and if you do, whether you survive with the least amount of collateral damage.

I will start with a very brief review of body fat and then will immediately link that science to COVID-19.  I also want you to know about my free e-book, The Covid Survival Guide, which you can get by clicking on the book cover image below and entering your e-mail address in the subscription box.  This book has research-based lifestyle advice tailored to COVID-19 for you and your family and I will be updating it periodically as I learn more and informing you of these important changes.

Brief Body Fat Primer:  Know Your Cytokines!

If you’ve read my book, listened to my podcast interviews, or have been following my blog, you should know that visceral fat (aka belly fat) is a topic I am passionate about.  If you are just coming to this blog for the first time, then I recommend you read this post so you understand this topic in more depth and at the very least watch a few minutes of my talk below at Google headquarters where I not only describe in detail the science of visceral fat, but also why it is more common in men than women.  I already cued the video, so just hit play and watch the short segment on body fat.

So from reading the post and/or watching the video, there are a few conclusions you should be able to make:

• Visceral (belly) fat is highly inflammatory
• Visceral fat is a storehouse of inflammatory chemicals which we actually call cytokines.  Don’t forget the term cytokines.  This will help connect the dots to Covid later in this post.
• Visceral fat affects men more than women.  Women tend to have a higher proportion of subcutaneous fat which is relatively non-inflammatory.  In other words it’s not pouring out cytokines.
• It takes very little visceral fat to produce lots of cytokines and inflammation, especially for high risk ethnic groups like Asians (Asian Indians, East Asians, etc.)

Bear with me here.  I promise to connect this to Covid in a moment.  Look at the image below and focus on the bottom left where you have the person with the visceral adipose tissue with a partial list of chemicals those fat cells release to the right.  I say partial because there are far more chemicals released by visceral fat.  I highlighted in red boxes, a few specific ones which I’ll list below to make it even more clear:

• IL-6
• TNF-alpha
• Angiotensin II

COVID-19 Connection to Body Fat

Now that you understand the concept of cytokines released by body fat, particularly visceral body fat, let’s return to COVID-19 and how it causes severe infection and death.  COVID-19 enters your cells using a receptor or doorway called ACE-2 (Angiotensin Converting Enzyme-2).  Upon entry the virus has a singular goal of replicating inside your cells but unfortunately for COVID-19 it only has an instruction manual (RNA genetic code), but no machinery.  COVID-19 essentially needs a 3-D printer to make copies of itself and that printer is found inside your cells, particularly your lung cells which are a major target for damage.

If your immune system is not successful at warding off COVID-19 and suppressing viral loads, then COVID-19 will multiply rapidly and a large number of these invaders will send a code red signal to your immune system which will then flood the site of attack with immune system cells and those inflammatory chemicals I discussed before…cytokines.  COVID-19 wreaks havoc when it actually teams up with the immune cells and cytokines from your very own immune system to damage and destroy your lung cells and other target organ cells.  The lung cells become severely inflamed, they fill up with fluid, and now become stiff so you become breathless.

A key point I want to highlight again is that severe illness and death results when a threshold amount of COVID-19 virus joins forces with a threshold amount of cytokines (and other immune cells) to work collaboratively to damage your lungs and other vital organs.

In other words, it’s a combination of viral load and cytokine load that appear to cause mass destruction.

See the image below from my COVID-19 survival guide that summarizes the process of viral entry, replication and the concept of viral load and cytokine load.  This is actually a short animation from one of my corporate presentations, but this screenshot gives you a nice glimpse of the process.  You can see the viral particle floating towards the ACE-2 receptor where it will enter and hijack the 3-D printer to make copies of itself.  I’ll explain the cytokine flame in a moment.

Your immune system isn’t deliberately betraying your body.  It has never before in human history seen a virus like COVID-19, and when this virus reaches a critical threshold, it throws every weapon it knows right at it.

As a side note, one of the key theories to explain why young children are affected less by severe COVID-19 complications is because their developing immune systems are sufficient to suppress viral loads, producing mild symptoms only, but not mature enough to generate a massive cytokine load.

One of the key switches inside our cells that serves as a volume control to amplify inflammation and cytokine load is the protein NLRP3 (aka NLRP3 inflammasome) pictured in the above image.  Covid-19 is one of many triggers for NLRP3 to activate this immune system response.  Many of the other health risks and conditions that are putting individuals at risk for a serious or life-threatening Covid infection act through NLRP3.  Animal studies like this show that visceral fat increases the expression of NLRP3 and this might explain one mechanism by which obesity, particularly abdominal obesity, increases not only inflammation, but the severity of Covid infections.

Chronic visceral fat accumulation (and other lifestyle factors) may just “prime” cells with a baseline amount of NLRP3 activation.  This is like having dry kindling and flickering flames present in your cells even before you’ve been infected.

Then when an outside offender like Covid shows up, one that preferentially likes to use NLRP3 as its pathway, it just stokes this flame into a massive wildfire.  By the way, the scientific term for programmed cell death by inflammation, typically triggered by an infection is fittingly pyroptosis, where “pyro” references the inflammatory flames pictured in the above image.

Now there is one other chemical released from fat cells that I highlighted in the red box from the prior section, which is Angiotensin II.  I added it to the image below in a solid red box.  I’m not going to go into detail in this post about the complex interaction between Covid, the angiotensin system, and blood pressure medications known as ACE inhibitors or ARBS.  The image below is from this article released in the New England Journal of Medicine which does an excellent review on this topic.

There are a few things I do want to focus on below.  The image beautifully illustrates how the spiky COVID-19 virus uses ACE2 to dock onto and enter our cell.  The angiotensin II which I highlighted below in the red box does several things that further damages our lungs and heart.  It constricts our blood vessels, it allows more fluid to enter our cells (vascular permeability), it causes direct damage to our lungs (“acute lung injury” mentioned in image), and it remodels our heart (“adverse myocardial remodeling” mentioned in image) in a damaging way.

Read this case study which highlights how individuals with no prior history of heart disease are developing severe heart complications like coronary artery disease (heart attacks), heart failure and inflammatory conditions of the heart like myocarditis and pericarditis.  Again, Angiotensin II mediates all of these damaging effects on your heart and lungs, and this is a chemical that is released by your visceral fat cells.

Additional Covesity Risks

So far I have only emphasized two of the MANY pathways (NLRP3 and Angiotensin II) by which obesity puts us at high risk for severe COVID-19 related disease.  Visceral fat is an armamentarium of several other flammable substances which I won’t get into here, but I do want to mention two other factors that are simpler to grasp, which are aerobic deconditioning and the mass effect of extra body weight on breathing.

Individuals carrying extra body weight are likely out of shape.  They get breathless with minimal physical exertion, and in many ways a COVID-19 infection is like the ultimate stress test for the lungs and heart, which will likely fail if they are not used to adequately conditioned.  That’s why I titled a recent blog post, Training for the Covid-19, as if it were a sporting event.

The mass effect refers to how extra body fat actually physically limits the normal elasticity of our lungs as we breathe in and out.  Obesity mechanically compresses the chest wall, lungs, and the diaphragm, making it very difficult to move air.

If you can’t move oxygen easily and naturally under the minimal to moderate physical stress of exercise, you will likely NOT be able to endure COVID-19 and may become dependent on a mechanical ventilator for support.

Now keep in mind that the mass effect of obesity typically happens at higher body weights, but the inflammatory cytokine storm and angiotensin II effect can happen with just a couple of extra inches around the waistline or just a few pounds of weight gain.  We don’t have an easy way to measure if your fat cells are pouring out excess amounts of cytokines and angiotensin II, but if you have any of the following risk factors, then there is a good chance you are:

• Increased belly fat: ethnic waistline cutoffs are here
• High triglycerides:  aim for triglyceride levels to be closer to 100 mg/dL or below
• Low HDL (healthy cholesterol): males should aim for HDL>40 mg/dL and females for HDL>50 mg/dL
• High triglyceride/HDL ratio: even better than looking at individual triglyceride and HDL, is to aim for a ratio of less than 3.0 (lower the better)
• Elevated blood glucose (prediabetes, diabetes)
• High blood pressure:  More recent research is showing that hypertension may be an inflammatory condition and the NLRP3 inflammasome might be a key switch as discussed in this study.
• Fatty liver: Learn more by reading my post here.  This mouse study shows NLRP3 is linked to NAFLD (non-alcoholic fatty liver disease) and blockade of this pathway leads to regression of fatty liver.
• Elevated hsCRP: this is a test for inflammation that is not indicated in all patients and can be elevated for various reasons.  Many of my patients with insulin resistance have elevated hsCRP and this study mentions the strong link between CRP and NLRP3 where NLRP3 appears to be predictive of elevated hsCRP levels.

You might recognize many of these as the same criteria for insulin resistance or metabolic syndrome.  The more of these criteria you have, the greater the likelihood that your fat cells might contribute to an impending cytokine storm.  By the way, ethnic groups like South Asians (predominantly Asian Indians), East Asians, Hispanics, and African Americans appear to be disproportionately affected by severe COVID-19 complications based on some of our US data to date.  These are also ethnic groups with a relatively high rate of insulin resistance and in the case of African Americans, hypertension is also accentuated.

Santa Clara county in California has a disproportionately high incidence of COVID-19 cases and deaths (as of the publication of this post), and some of this may reflect its ethnic make-up which reflects the high risk groups I mentioned, and is especially pronounced in Hispanics and African Americans due to significant socioeconomic and health care access disparities.

Track Your Numbers

One way to keep yourself more accountable is by tracking your body weight every single day and also pay attention to waistline as well.  I actually am checking my weight twice a day, upon waking and bedtime, because this is automatically moderating my behavior during a highly stressful period where I am susceptible to eating unhealthier.  There is natural variability in body weight from morning to evening, but tracking your numbers regularly gives you a good sense of what your optimal morning and evening weight range is.

You should also keep track of your waistline measurement either formally using a flexible tape measure or at least casually by noting how your pants fit.  Many of us (including myself) are living and working in pajamas and sweats with generous elastic waistbands.  Put on your jeans or work pants periodically and see how they fit.  Don’t get surprised by the “Quarantine 15” or the “Covid-19 (pounds)” weight gain.

In terms of other health numbers, some of my patients are using continuous glucose monitors (CGMs) which I wrote about in detail here or using other health markers like the one from my blog post on the 7 numbers I track for weight loss and health.  Again, be extra vigilant since many of you are now spending more time at home and have more restricted access to doctors where you might have been tracked more closely.

The Urgency of Covesity and Why You Must Act Now

I hope the science I provided so far has been clear and convincing.  Essentially, carrying extra visceral fat means your body is already providing an extra dose of cytokines to your body, even before you’ve encountered COVID-19.

If you are carrying extra body fat, especially around the waist, you are giving this disease a generous head start by providing the very supplies it needs in advance to produce a massive cytokine storm.

I’ve said over and over in prior posts how chronic, persistent inflammation (aka immune system activation) is linked to almost every major health condition imaginable (heart disease, cancer, alzheimer’s disease, etc.).  For many of us, those diseases may feel like distant threats we don’t need to address at this moment, but COVID-19 is here right now, armed and ready to do immediate damage.

I think individuals are being lulled into thinking that this pandemic will magically go away in a few months.  Flattening the curve simply means transiently putting out a fire, but other fires will continue popping up all over the US and the rest of the world for many months to come.  Until we have a vaccine, which will take a minimum of 12-18 months (from publication of this post), the only way to eradicate this virus is for us to develop what’s called herd immunity.

According to renown infectious disease expert and leading authority on COVID-19, Dr.Michael Osterholm, who was interviewed by my colleague and friend, Dr.Peter Attia on his podcast here, 50-70% of the population needs to become infected with COVID-19 to stop its spread.  That would ensure that humans collectively have enough circulating antibodies to prevent COVID-19 from successfully spreading.

Now if that’s the case, you need to pretty much assume that you have a very significant chance of being infected by COVID-19 despite all of your efforts to avoid being infected.

All of a sudden the game is shifting from “you (COVID) can’t catch me,” to “now I know you’re probably going to catch me, but I won’t let you kill me (or disable me).”

You need to continue hand hygiene, social distancing, and all other preventive measures, but just as critical is incorporating lifestyle measures to keep you fitter, leaner and healthier.

Changing Your Lifestyle Is A Community Responsibility

Some of the patients I have been communicating with so far have actually adopted an even unhealthier lifestyle that is putting them at greater risk.  Unfortunately many already came off a winter where they overate, were inactive and gained extra pounds.  Usually the first part of the new year is when my patients rebound with healthier lifestyle changes, but now the pandemic lock-down has actually exacerbated their health further.

Individuals have become more inactive, they are eating unhealthy foods and snacking constantly, they are consuming digital media almost around the clock, they are experiencing high levels of stress without any practices to manage it, they are going to bed later than ever, and their daily schedule has become haphazard which in turn throws off their circadian rhythm.  They are creating the exact metabolic and inflammatory conditions that are highly conducive to COVID-19 causing a serious and potentially life-threatening infection.

I went through these unhealthy adaptations too when I first was adjusting to my new pandemic world, but now I’m meditating and exercising more than I ever have.  I’m deliberately adding more nutrient-dense foods to my meals and snacks.  I need to be in the best shape of my life for me, my loved ones, and so I can serve my patients and community in their time of need whether its live patient care, using video visits, or raising awareness through lectures and writing.  I view my dedication to my own health as a community benefit during this time.

I don’t want to occupy a hospital bed, a ventilator, or some other health care resource that someone else needs.

I strongly encourage each of you to use this pandemic as an immediate call to action to take care of your own health, your family’s health, and an opportunity to serve your community directly through public service or indirectly by just staying healthy and not transmitting disease.

Resources to Help You

I wanted to share a few resources to help you manage your health through this pandemic.  Click on the book cover below if you haven’t already to get your free COVID-19 Survival Guide copy.  This book has research-based lifestyle changes that address COVID-19 specifically, the NLR3P inflammasome, and general immunity.  The link will also take you to a dedicated resource page where I’ll share research and practical lifestyle tips on Covid-19.

My Whole Family Health Program is also now 20% off if you use the coupon code COVID for a limited time.  This program uses innovative animations and provides practical lifestyle content and resources to educate and motivate adults and children to make healthy lifestyle changes and is targeted at all of the risk factors discussed in this post.