Poor nutrient status is associated with obesity, inflammation, and oxidative stress, which impact the immune system. With the global epidemic of obesity aligning with the pandemic of COVID-19, a new and urgent focus on obesity and diet is warranted. This article will examine the reason for poor COVID-19 outcomes in obese patients and present some promising interventions that may offer therapeutic efficacy against COVID-19 in the obese.
Nutrition and Diet
The history of our dietary habits is a fascinating one. Interestingly, many people are actively choosing to live in a way similar to their pre-canning ancestors. More fresh food, laden with fiber and natural nutrients, is making its way onto our tables. Unfortunately, despite this shift, the majority of the adult population in the United States is deficient in micronutrients as a result of the overconsumption of high-calorie, low-nutrient processed foods.
Processed foods are chemical-laden, highly-addictive foods that are usually packaged. Scientifically, we have access to decades of research confirming that diet quality has a huge effect on the overall physical and cognitive condition, eye health, bone health, vascular status, and the immune system.
Food should rot; it is laden with microbes ready to chow down on it. Preventing food from rotting is a huge industry that has birthed our taste for processed goods and that, sadly, has made choices that are to the detriment of health – except for that marvel of technology: refrigeration! Healthy eating is not complicated, but it does require that people recognize the danger and (deliberate) addictiveness of packaged and processed foods.
Our ancestors ate in this way due to necessity. The time has come for us all to choose such a diet, one that:
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- Emphasizes vegetables, fruits, and whole grains
- Includes lean meats (i.e., poultry and fish), beans, eggs, nuts, and dairy
- Limits saturated and trans fats, sodium, and added sugars
- Controls portion sizes
Does Obesity Impact COVID-19 Outcomes?
With nearly 40% of American adults (and nearly 20% of children) qualifying as obese, there is an ever-increasing awareness of the issue. Diet-induced obesity is a serious health risk and reduces life expectancy. Obesity is a strong risk factor for type 2 diabetes, fatty liver disease, heart disease, sleep apnea, metabolic syndrome, osteoarthritis, and some cancers – among other conditions.
The COVID-19 pandemic has further focused attention on obesity when it emerged as a significant risk factor in expected outcomes. Analysis has revealed that individuals with obesity are at greater risk of hospitalization (113% higher), ICU admission (74% higher), and mortality (48% higher). These alarming statistics are more than just numbers as they indicate increased risks caused by obesity. Adipose tissue is not inert, it disturbs the metabolism, a key outcome of which is reduced insulin sensitivity. The body then responds by producing higher levels of circulating insulin, which, in turn, leads to a range of issues, including increased production of inflammatory cytokines (signals released by immune cells that promote inflammation).
COVID-19 and the Cytokine Response
In some individuals, a COVID-19 infection is accompanied by an aggressive inflammatory response. If a large amount of pro-inflammatory cytokines are released, these may create an event known as the much-publicized “cytokine storm.” This upheaval arises when the innate immune response releases excessive pro-inflammatory cytokines. Immune cells, such as tissue macrophages and mast cells, as well as endothelial and epithelial cells, are all major sources of cytokines. The “cytokine storm” arises from a sudden and acute increase in the circulating levels of these pro-inflammatory cytokines, including IL-6, IL-1, TNF- α, and interferon.
The result of cytokine release is an influx of various immune cells such as macrophages, neutrophils, and T cells to the site of infection. An excessive response destroys human tissue; interfering with endothelial cell-to-cell interactions, damaging the vascular barrier, creating capillary and alveolar damage. This alveolar damage is one consequence of the cytokine storm that can progress to Acute Respiratory Distress Syndrome (ARDS). It is ARDS that results in the low oxygen saturation levels reported as a major cause of mortality in COVID-19.
The cell damage can be so great that this excessive inflammatory reaction is directly correlated with the observed lung injury, multi-organ failure, and unfavorable prognosis of severe COVID-19. It makes sense, then, that obese individuals with pre-existing raised levels of inflammatory cytokines are particularly at risk of death because of COVID-19.
Improving COVID-19 Outcomes for Obese Patients
With a clear correlation between obesity and COVID-19 outcomes and a convincing explanation for the causative link between the two, an obvious question comes to mind: can COVID-19 outcomes be improved in patients with obesity?
And, the answer is: we’re not sure. However, there are some very interesting theories and promising results, and it is these that we will present here. Early reports suggest that the following compounded nutrients may be beneficial:
- Metformin/Alpha-lipoic acid/Chromium capsules
- Ketone bodies
- Vitamin D oral or intramuscular injection
Metformin is an FDA-approved prescription medication to treat diabetes. It decreases glucose production by the liver and increases insulin sensitivity. By restoring insulin sensitivity, circulating levels of insulin will fall, and, therefore, the consequences of high-levels of insulin production will be mitigated.
As discussed above, one of these consequences is a state of chronic inflammation. Theoretically then, metformin is considered to be a good candidate for improving COVID-19 outcomes in obese patients. Early results support the preventive use of metformin (before infection with SARS-CoV-2) to prevent severe COVID-19 in patients with diabetes or obesity.
Alpha-lipoic acid (ALA) is a naturally occurring compound made by the body. It is known for its efficacy in reducing insulin resistance in diabetic patients. This puts ALA into the same theoretical model of action as metformin. If you can improve insulin sensitivity, then the inflammatory effects of high levels of circulating insulin may be mitigated, and COVID-19 outcomes improved.
Interestingly, ALA has also been shown to raise the intracellular pH. Studies have demonstrated that as the intracellular pH increases, the entry of the virus into the cell decreases, which may strengthen the human host defense against SARS-CoV-2. This finding suggests that ALA may prove an effective therapy for COVID-19 patients. And, the results of the first randomized control study support this idea, with reduced mortality rates in the treatment group.
Another promising approach to improving COVID-19 outcomes is the use of ketone bodies to induce a ketogenic state in the patient. Ketones arise naturally from metabolic processes. Achieving ketosis via a ketogenic diet is already a treatment for certain conditions and is also considered a weight-loss management strategy. A ketogenic diet (high fat, adequate protein, and low carbohydrates) is one that forces the body to utilize fats as an energy source.
Supplementary ketones typically exist as liquids or dissolvable powders that contain ketone bodies or ketone precursors, such as ketogenic medium-chain fatty acids or ketone mineral salts. Ketone bodies have been shown to have multiple beneficial effects, including decreasing oxidative stress and inflammation.
It is hypothesized that initiating a ketogenic state via a moderately high-fat diet together with ketone supplementation at the first signs of respiratory distress due to COVID-19 will moderate the innate immune response and the associated cytokine storm. Clinical studies are most certainly warranted in this instance.
Improving COVID-19 Outcomes by Treating Nutrient Deficiencies
One of the great ironies of the condition of obesity is that it often goes hand-in-hand with nutrient deficiencies. And, years of research have demonstrated that essential micronutrients play important and complementary roles in supporting the immune system and preventing infection. Deficiencies in such micronutrients compound the risk factors for obese individuals in terms of their COVID-19 outcomes. The great news is that treating such deficiencies is fast and effective through the use of supplements.
Vitamin D deficiency is highly prevalent in the US population, and low vitamin D levels have been associated with an increase in inflammatory cytokines, a greater risk of pneumonia, and viral upper respiratory tract infection. Vitamin D supplements increase levels of circulating regulatory lymphocytes, which are known to defend against unchecked inflammation and viral infection.
With the results of the first studies now in, supplementation with vitamin D has held up to its theoretical promise. In a randomized controlled trial, patients receiving vitamin D supplementation saw improved SARS-CoV-2 viral clearance compared to the control group.
Trivalent chromium is an essential trace element found in a wide range of foods. The evidence is collecting that chromium plays a role in maintaining insulin sensitivity and has been shown to restore insulin sensitivity in diabetic studies. This factor puts chromium into the same theoretical mechanism of action as metformin and ALA, in that it may promote a beneficial reduction in circulating levels of insulin, leading to helpful immune moderation.
The picture is not simple, however, with regards to chromium. An early retrospective study demonstrated that whole-blood chromium was higher in severe COID-19 patients. Remembering that correlation is not causation (a vital component to any such data interpretation), further clinical studies are warranted to offer an explanation for such an apparent association.
Safe Application of Therapies
It is vital that all supplementation and application of therapies is achieved safely. For example, supplementing with trace elements or vitamins should only be conducted in patients with existing deficiencies. Reach out to our team for additional information.
For anyone in the high-risk groups, the COVID-19 pandemic is a deeply disquieting time. While mitigating against existing comorbidities is an effective strategy, the best defense against the virus is acquired immunity against the virus itself – which is why the world has waited with such anticipation for viable vaccines to arrive on the market.
Covid-19 Vaccinations at VLS Pharmacy
VLS Pharmacy is currently administering the Moderna Vaccine by appointment only. Before making your appointment, please visit the New York COVID-19 Vaccine Eligibility page here to determine your eligibility. If appointments are unavailable, please check back frequently as New York State is systematically allocating vaccines. As we receive more vaccines, more spots will open.
Please note: we CANNOT book your appointment over the phone due to the screening requirements.
All medications from VLS Pharmacy and New Drug Loft are prepared in a lab that follows safety and quality standards per our status as a 503A pharmacy.
Reach out to our team to learn about best practices and to partner with our experts on custom medications for your patients.