May 16, 2020

 To date the modeling data and infection fatality rate data are minimally useful. Statistically, we have already had more deaths than any seasonal influenza outbreak in recent memory, yet, we do not have a clear understanding of the true infection fatality rate for novel SARS2. Recent models continue to pit the IFR between 0.3 and 1.3, which is definitely worse than the flu. More testing and more analysis should get us closer to the truth as opposed to computer modeling guesswork.

 Coronavirus Update 10

 National poverty is going to worsen because of the unprecedented COVID19 lockdown. Unemployment just hit 15% and this is a dubious mark not seen since the Great Depression! This is a major recipe for childhood disease and mental health dysfunction as poverty has always been the fastest route to an unstable environment for a child to attempt to thrive in. The effects of COVID will be unmistakeable.

Children have proportionally and remarkably been protected from the ravages of SARS2/COVID19 the disease as those individuals expiring from the virus's pathologic attack are doing so because of physiologic changes of advancing age coupled with inflammatory metabolic disease and dysfunction that is driven by chronically poor lifestyle choices and negative public policies that prey on the poor, young and least among us. Adults, and not children, that are marginalized or prone to disease based on lifestyle choices will struggle further with COVID as poverty rises while children will lose from general poverty induced disease. We need to prepare for these disparate events in the clinic space and out in the community.

The cause of the antecedent and accelerated current poverty problem is clear, however, like natural disasters, viruses and bacteria have been with us since the dawn of time and are not going away, EVER! They will continue to show up, cause trouble and exist. Frustratingly, the SARS2 pandemic is a Darwinian reality play playing out before our eyes. Survival of the fittest is happening with SARS2 as the targeted guillotine for those with inflammatory risk. This is a dispassionate fact. The economic fallout appears to be act two where children enter the play in great numbers.

Let us look at this issue from two angles, those at significant risk from SARS2 and part 2, children.

Understanding the science behind the immunology of SARS2/COVID19, as we have discussed over the last 2 months, points clearly to a singular modifiable problem, food. This is not to say that other factors are not at play here, but we know that humans are at significantly increased risk of dying if they consume a diet that increases baseline immune inflammation. This occurs by multiple mechanisms. Simplistically, one mechanism is when diet induced fat cells accumulate around your organs, multiply and engorge, they release large volumes of cell signaling inflammatory cytokines in an effort to regulate the dysfunction of the chronic diet. This can occur if you are obese or skinny, what some people call "skinny fat". The inflammation is the problem not the physical appearance. The NLRP3 inflammasome department of our innate immune system, upregulated by SARS2, is highly sensitive to uric acid, excess glucose and saturated fats. Remember that high fructose corn syrup converts to uric acid as a breakdown metabolite. These food and beverage driven events leave the immune system angry, activated and working overtime to help us survive as we cripple it with the next frappuccino and donut breakfast. The poor quality diet is chronic, microbiome and immune crippling to the susceptible individuals. SARS2 just came along and decided to be a virus. The disease outcome burden would be dramatically less if the antecedent triggers were mitigated long before SARS2 decided to show up.

Therefore, the big question is, why are we, Americans, so prone to inflammation? The answer is myriad but highly related to our personal lifestyle choices, societal food production companies prioritizing profit and taste over health and vitality, and governmental policies that make life harder for the poor and children.

Poverty should not be a major determinant of our health through food. However, public food policy is broken. Let me say that again, public food policy is broken. For over 30 years, we have done a terrible job feeding America. Kids routinely consume government sponsored low quality high calorie refined processed foods for 2 meals a day in school. They become unhealthy adults that eat government subsidized tasty fast food on the run multiple times a day in order to make it through a stressful work day wondering why they don't feel great in general day to day life. You can blame the individual if you wish because they did make the choice to eat unhealthy food. I would rather look to the leaders who should be leading by example and providing appropriate food stuffs for health. If you are going to give to the disadvantaged, give real food that is nourishing and full of life sustaining nutrients. If you are going to subsidize a food with my tax dollars, I would prefer that fresh fruits and vegetables end up cheaper on my plate.

The United States Federal government via the Farm Bill provides massive subsidies for the staple storable commodities, corn, soy and wheat, keeping prices way down for the wrong foods. As Michael Pollan wrote back in 2008: "There are several reasons health care has gotten so expensive, but one of the biggest, and perhaps most tractable, is the cost to the system of preventable chronic diseases. Four of the top 10 killers in America today are chronic diseases linked to diet: heart disease, stroke, Type 2 diabetes and cancer. It is no coincidence that in the years national spending on health care went from 5 percent to 16 percent of national income, spending on food has fallen by a comparable amount - from 18 percent of household income to less than 10 percent. While the surfeit of cheap calories that the U.S. food system has produced since the late 1970s may have taken food prices off the political agenda, this has come at a steep cost to public health. You cannot expect to reform the health care system, much less expand coverage, without confronting the public-health catastrophe that is the modern American diet."

What I am basically saying is that government provided unhealthy foods and corporate fast/processed foods have flooded our society for decades making humans ticking time bombs for a pandemic virus to come by and wreak havoc, and it is. This is the antecedent problem to all health disparities in America including COVID deaths. We can clearly not count on our current or past governments to make good decisions for us around food policy as there has been no actionable change sine Michael Pollan wrote his manifesto in 2008 or before. We must act on our own with our own self determination and desire to survive disease free and full of vitality.

Now comes the rub. The negative change in employment status for many is forcing a struggle to make ends meet for food, rent and much more. Poverty and unemployment are skyrocketing because of the lockdown and work stoppage. First, let me say that I am sorry that we are in this position as a country filled with chronic disease and poverty when we could have prevented it with better education and better public policy around food, pollution and money. Alas, we are here and we have to take the bull by the horns to change our health trajectory.

No matter where one is today on the poverty continuum, the first and most important issue is survival. Survival in most cases is predicated on reducing total body inflammation. Thus, the principle precursor of inflammation, COVID and health outcome shifting is the consumption of processed poor quality foods loaded with refined flour, sugar and saturated fat. Therefore, step one is to avoid all processed foods that are loaded with these macronutrients. This is a lifesaving intervention for your immune system. This simple change could and should be enough to tip the balance toward survival for an at risk individual depending on age and severity of hypertensive or diabetic disease at baseline. Frankly, there is nothing to lose by this alteration. Second, replace all of these foods with whole and minimally processed colorful foods primarily in the vegetable and fruit category. Third, if medically possible, eat only 1 to 2 meals a day and limit the consumption of meat as it is expensive as a line item on your grocery bill. Take the money that is saved and apply it towards more fresh or frozen fruits and vegetables. Fifth, eat more beans and whole grains as they are cheaper but still high quality foods. Taking this approach will reduce risk, save much needed money and set one on a goal for total health revitalization for the future.

I think back to when I was very poor in medical school. I often ate ramen noodle soup that I would add an egg, spinach and carrots to for health benefits. Frozen vegetables with butter and a side of rice was a staple. Peanut butter filled the celery well for a snack. We did the best that we could. .

Lifestyle choices have always dictated a Darwinian outcome for some if not most,

Next week Part 2 Children and poverty:

Dr. M


Kaneganti Nature Immunology Article
Donath Nature Immunology Article
Andersen Advances In Nutrition Article
Michael Pollan Article
Wang Lancet Article
Gandhi NEJM Article
Google Scholar Search for obesity and immunology