COVID-19: What we do and don’t (yet) know and how to reduce your risk
The COVID-19 pandemic is a monumental example of the limitations of sound-bite driven media.
Although there is a constant stream of hype, paranoia, political positioning and finger-pointing over the past weeks, there has not been a lot of discussion about what we can do to move forward in a balanced manner.
We all have a personalised media feed that allows us to live within our own echo chamber which makes it harder to hold a global, evidence-based discussion.
So, I thought it might be useful (and at least therapeutic for me), to share some thoughts about:
- what I think we do and don’t know about COVID-19, and
- what we can do to proactively manage our risk and get on with living our best life.
Time is of the essence! We need to act swiftly, adapt and balance critical parameters, including:
- personal health,
- our medical system (and the people who work in it),
- our economy and employment,
- our mental health, and
- the social fabric of the local and international community.
I hope this article will stimulate some useful thinking and discussion about how we can intelligently move forward.
- COVID-19 modelling and data are incomplete, but we need to work with what we have.
- When something is growing exponentially (e.g. doubling every four days) you need to act swiftly. Early intervention buys time to make better decisions when more information comes to hand. But we need to be prepared to collaborate internationally and continually refine our models and update our approach.
- Many countries are now in lockdown, but the next steps are not yet clear. Waiting indefinitely for a safe vaccine may not be a viable strategy.
- People won’t continue to endure lockdown if they can’t see why they need to do it. The modelling that supports the decision-making needs to be transparent and publically available.
- The rate of spread of the COVID-19 virus is influenced by a range of factors including population density, testing and tracing, and social distancing in each location.
- We need to balance factors such as public health, hospital system capacity, mental health, employment and the economy.
- In addition to deaths and confirmed tests, antibody testing will give us a better idea of how widespread COVID-19 already is in the community and how many people have already developed immunity.
- Obesity and metabolic syndrome appear to be the main risk factors for a more severe outcome when exposed to COVID-19.
- While you shouldn’t try to “boost your immune system”, obtaining adequate nutrients play a central role in supporting a healthy immune system response.
- Optimising your nutrition and your metabolic health is one thing you can do now to minimise your risk of having a worse outcome and becoming a burden on the already overstretched health system.
The data on COVID-19 is incomplete (but we need to work with what we have)
We like certainty. But there is no such thing as perfect data, especially when it comes to something like a virus.
There will be errors. No dataset will ever perfectly represent reality.
Engineering, modelling and infrastructure planning (my day job) are all about using the data available to make the best decisions possible in view of the risks and unknowns.
Where we don’t have good data, we need to be more conservative.
When more data is available we can be more confident.
For example, if I can know the exact mass of all the trucks that will use a bridge over its lifetime and the precise material properties of the steel and concrete to be used, I can design a cheaper and more efficient bridge. But if we don’t have good data, we need to be more conservative. This results in a chunkier, less efficient and more expensive structure.
Good decision making in engineering revolves around continually refining the input data, calibrating the models and using it to make the best decisions possible.
Time is of the essence!
While we have had hundreds of years of accumulated data on bridge design and well-developed codes, we can’t wait for perfect data when something is moving as fast as a pandemic.
If all we do is sit around bitching and moaning about the multitude of ways that the data is less than perfect and who is lying to who, we will get run over by this thing!
We need to be willing to collaborate, update, refine and pivot quickly as more data becomes available and our models are refined and calibrated.
It’s not that the modelling is crap, and therefore should be thrown out. Any good modelling needs to be progressively calibrated as better data becomes available.
We need to be nimble and dynamic!
When I first wrote about COVID-19 five weeks ago, the numbers were fairly low (outside China). But the exponential growth in reported cases across the world through March 2020 was troubling.
Being married to someone with Type 1 Diabetes and having been advised by friends ‘in the know’ that COVID-19 was about to become a serious issue, we chose a conservative approach as a family early on.
Meanwhile, many people were commenting on how few people had been infected compared to other conditions.
But, simply looking at the current numbers fails to account for the potential for something to grow to become a major issue without some form of intervention.
When something is growing exponentially (e.g. doubling every four days) you need to consider the implications and act early if you are ever going to change its trajectory.
Many countries were seeing their health system overrun with more people dying without access to adequate health care. Doctors and nurses were dying as they became exposed to a large viral load of COVID-19 (i.e. a larger dose seems to be more dangerous than a small one). Since then, the number of confirmed cases has continued to grow.
But the good news is that partly through the efforts of many countries to ‘flatten the curve’, the growth rate of new cases appears to be slowing in many areas.
As they implement some form of social distancing, many countries are starting to fall off the ominous trajectory of continued exponential growth. (COVID Trends is a cool way to see how the initiatives to slow growth are working in your area.)
While social distancing and lockdowns are certainly not a viable long term solution, they buy some time to plan the next steps and ensure we are appropriately prepared.
But what do we do now?
But, having slowed the growth in many areas, what do we do next?
What data can we use to make wise decisions?
It’s like we’ve caught a poisonous snake by the tail. If we let it go it will just come back and bite us.
The answer, as it often is, is “It depends.”
While densely populated areas like New York and Italy are scrambling to manage the pandemic, geographically isolated countries like Australia and New Zealand seem to be on a path to squashing the curve rather than flattening it (at least until there is a second wave when restrictions are relaxed).
It’s worth noting that it was the second wave of the Spanish Flu in 1918 that was the most deadly. This came at the end of WWI when people were starving, malnourished and hence immune suppressed. In our current situation, we have the added complexity of obesity and malnourishment due to a highly processed modern diet.
The reality is that even if we can suppress and slow the spread of COVID-19 now, there is nothing stopping it raising its head at a later time. The outcome of such a second wave could depend on whether we use the intervening time to prioritise nutrient-dense foods and focus on getting fit, healthy and lean. However, this will be more challenging for people if they are unemployed and can’t afford quality food which is already out of reach for many.
In Australia, the number of active cases is on the way down. (This 10-day forecast tool from the University of Melbourne seems to be the best forecasting data available in Australia.)
It’s also nice to see growth in the US slowing.
But America is a big place and you hear different stories from different people in different locations.
New York has been through a lot of pain, with nearly 12,000 deaths, overwhelmed hospitals and a lack of ICU beds. The chart below from covid19.healthdata.org shows that cases in New York requiring intensive care have outstripped their capacity (the horizontal green line is ICU capacity while the dotted line is the projected ICU demand).
We also know that better access to health care increases your chance of recovering. Limited availability of hospital beds increased the death rate in Wuhan from 0.16 to 4.9%.
Limited resources need to be intelligently managed to ensure adequate capacity as the need for care of COVID-19 patients peaks in various locations. Thankfully, the death rate, with strict lockdown, seems to have reached a peak in New York.
Meanwhile, many other areas in the US and the world that are not as densely populated have nearly empty hospitals and minimal cases but are still in lockdown. Viruses don’t spread in rural country areas as quickly as they do in Manhattan where everyone takes the subway to work.
Many nurses are reporting that they are getting their hours cut as the COVID-19 cases that they planned for haven’t materialised and the hospitals have cut their other normal services (which also has flow-on health complications).
Sadly, this does not seem to be efficient resource allocation, especially when the medical systems across the world are already overstressed and underfunded.
By contrast, we have Sweden, where the authorities are taking a less restrictive approach and intentionally allowing a level of “herd immunity” to develop (rather than waiting in hiding indefinitely for a safe vaccine).
Sweden’s hope is that once enough of their population has been infected and have recovered (and hopefully acquired immunity), they will be able to get on with their lives without closure of their borders every time they see a small breakout of positive COVID-19 cases.
So far, Sweden’s death rate hasn’t been diabolical, but the modelling suggests that, without a government-mandated stay at home order, closure of their educational facilities or travel bans, they will experience a peak of in late May.
The upside though, is that once this is over with, they will no longer have to live in fear of a dreaded second wave. They will be able to put COVID-19 behind them while the rest of the world continues to actively manage it indefinitely.
Sweden’s approach will be an interesting experiment to watch over the coming weeks and months. It will be one more piece in the jigsaw of COVID-19 data that will help us make better decisions.
We need to quickly refine our models using the latest data
Models are never perfect. But that shouldn’t stop us from using them to make decisions.
Good models that consider disease risk, deaths, the economy, our social fabric and the people who understand how to use them, are crucial to making timely decisions at the moment!
Here’s hoping we can continue to refine COVID-19 modelling on a location by location basis to understand how to balance factors such as:
- public health,
- the capacity of the hospital system, and
- the economy, and
- mental health, and
- our social fabric.
There are obvious reasons that we don’t want to stretch any of these to breaking point. We need to carefully, thoughtfully and collaboratively balance these critical factors.
Optimising Nutrition advisor Bev Postma noted, “In my view, the lack of serious international collaboration and joined-up thinking will emerge as one of the biggest failures of this pandemic.”
Ideally, these models could be shared with the public to ensure they understand why their local government is taking the approach that they are. While we don’t want to create mass hysteria, without transparency and trust people won’t comply with restrictions for very long.
The importance of antibody testing
Going forward, rather than death rates or confirmed COVID-19 cases, it will be critical to understand how many people have already been infected with minimal symptoms and are now immune.
Our innate immune system is our first line of defence to a new virus like COVID-19. But once we have recovered we develop antibodies our adaptive immune system knows what to do next time it sees the same virus and we don’t get nearly as sick.
This is another area that we’re still learning about, but there are examples of emerging studies that indicate that more people than we previously thought have developed antibodies, and hence are likely to be immune to COVID-19, for example.
- Antibody research indicates coronavirus may be far more widespread than known
- Coronavirus antibody tests could be the key to reopening Italy’s economy
- COVID-19 Antibody Seroprevalence in Santa Clara County, California
- Coronavirus clue? Most cases aboard U.S. aircraft carrier are symptom-free
- Iceland lab’s testing suggests 50% of coronavirus cases have no symptoms
- Update on SARS-CoV-2 / COVID-19: Testing
While testing and tracing contacts of people who become sick is a useful way to contain and manage the initial spread of the virus, it may not be as valuable if the vast majority of people who are infected don’t experience symptoms. If this is the case, then there are likely a lot of people walking around who have the virus without symptoms but who are somewhat infectious.
Also, it is possible that COVID-19 has been around for longer than we initially thought and before widespread testing was available. If this is the case then our models may be overly conservative (i.e. predict more cases that we will see in reality). This is why calibration of the models with actual data in each location is critical to getting a better handle on what we are actually dealing with.
Once we have a better understanding of the number of people that have already developed antibodies in the community we can get a more accurate feel for the risk of this new virus.
We can also make more informed decisions about who can get on with their lives (e.g. young healthy people who have already recovered and are now immune) vs who should continue to manage their risk of exposure (e.g. people with a higher level of risk factors such as age, obesity, diabetes, cancer etc) as some degree of herd immunity inevitably develops.
Hopefully, before too long, more people will have cheap and easy access to antibody testing that will enable them to understand if they have been exposed and recovered (even without developing significant symptoms).
Personally I would be interested to see if I had been exposed to COVID-19 already. Was that dry cough we had a month ago while taking the crowded bus to work COVID-19? The rest of my family also had unusual symptoms that were hard to shake.
Many people have reported that they have had peculiar symptoms. Is this just psychosomatic or were they actually exposed to COVID-19 and couldn’t get access to testing?
Again, we don’t know.
But this knowledge would be valuable to help you know how risk-averse you need to be going forward.
People who have developed immunity could potentially get back into the workforce without fear. People who are able to build immunity with minimal symptoms will have a significant advantage over the rest of the population!
People who have already developed immunity could also donate their antibodies to help more vulnerable people build immunity in the absence of a vaccine. This would make blood donation an even more worthwhile habit and reduce our reliance on a vaccine.
Will we become immune and recover once exposed to COVID-19?
We also don’t know for sure if we will develop long term immunity to COVID-19 once exposed.
There are reports of people being reinfected, however, this may just be incomplete recovery or inaccurate test results. Again, we don’t really have enough data yet to know for sure.
But if this is the first virus that humans can’t develop immunity to, we’re all pretty much screwed in the long term! The good news though is that this is highly unlikely given the number of people we are seeing that are developing antibodies with minimal symptoms.
What are our options?
For now, it seems we have three options:
- Do nothing and allow COVID-19 to sweep through the community,
- Stay in lockdown until there is a safe, effective and widely available vaccine, or
- Intelligently manage restrictions on a location by location basis to ensure that:
- hospitals are not overwhelmed,
- doctors and nurses don’t die due to inadequate support and personal protective equipment,
- allow people to get back to work and the economy to recover.
We can’t make blanket recommendations on what the best course of action is for every country, state and city. Ideally, we need to ‘thread the needle’ to get the right balance on location by location basis.
While we want to save every life, and it sounds morbid to allocate a financial value to a year of life lost, we do need to consider whether the cost of the intervention is appropriate. Check out the article A Health Economic Perspective on COVID-19 by Dr Malcolm Kendrick for a glimpse of the costs of the current interventions and have a think about what that money could be used for in other areas to save lives or improve the quality of life elsewhere.
Also, for an example of some strategic and robust thinking check out Our Plan B: The Way Out by a group of New Zealand academics who are questioning what happens after they lift their aggressive lockdown in what has been a successful campaign to wipe out COVID-19 in NZ.
We don’t know the real risk of COVID-19
There is a wide range of figures to look at when it comes to COVID-19 death rates. At the upper end, we can see in the data below from Worldometer that of confirmed and tested cases that have been closed (i.e. either recovered or died), 18% are dead.
A 18% death rate is certainly a scary statistic! If this is what we’re dealing with then we probably should all stay inside and make the best use of the time we have left!
But if you stand back and look at the number of confirmed cases we see that of the 2.2 million cases 150 thousand are dead we get a slightly less scary death rate of 6.8%.
But then if we assume that 80% of people who have been exposed have not been sick enough to get a test that number comes down to 1.4%.
And then, if we assume that COVID-19 has been spreading for some time and many people are already immune and 10% of people who have been exposed managed to get a test, that number comes down to 0.6% (which is what many people are predicting based on previous pandemics).
While it can seem like a callous way of thinking, if we’re looking at a death rate of 0.6% and primarily in people who didn’t have long to live anyway, this is nowhere near as scary as the initial numbers lead us to believe.
But again, we just don’t have the data to know how close the infection fatality rate is to 0.6% or 21%.
Having a better handle on this denominator (i.e. through widespread antibody testing) will help us understand the actual risk and hence how we should manage it going forward. We just don’t know this yet, but in the coming weeks, we will start to get a much better understanding.
Can we wait for a vaccine to save us?
It appears that the game plan of many governments is to wait in lockdown for a safe vaccine to save us.
Unfortunately, safe and effective vaccines take years if not decades to develop and they are still not without their risks. It’s worth noting that, partly due to the complexity of the virus and the many side effects, a vaccine has not been released for SARS in the past 17 years since the initial outbreak in 2003.
Artificial Intelligence modelling evaluated the likely timeline at more than five years for two of the forty vaccines under development and gave neither a high chance of success.
“A vaccine cannot be the end-game. It cannot be what we all are waiting for to resume normality. Vaccines are designed to stimulate the immune system and interferon production. That is the very mechanism this virus uses to kill you. Developing a successful vaccine without side-effects is going to be very challenging in this case. “
If a vaccine does come to market, it is also worth noting that you need a healthy immune system to develop your own antibodies.
The primary issue with this ‘plan’ is that we may not be able to wait that long.
How long can we continue to hide away as unemployment rises, governments go deeper into debt and people go crazy being locked up.
Not to mention if fragile supply chains become disrupted and food starts to become hard to come by. While March 2020 was the first March since 2002 that there were no mass shootings in the US, it’s worth noting that many people not only stocked up on toilet paper and Oreos but also guns and ammunition in preparation for the pandemic.
With the medical system previously stretched, we owe it to ourselves and our community to do what we can to reduce the risk of the virus on us and our potential to be a burden on our society.
We are quickly learning about the risk factors that lead to a worse outcome
It can be extremely stressful to continually look down the barrel of a pandemic that may kill us or our loved ones with no solution other than to wait for a vaccine that is years away.
However, we can gain a lot of peace once we understand our risks and ensure we are doing everything we can to manage them.
Once you know you are doing everything you can there’s no need to stress.
So what do we know about the risk factors for COVID-19 and what can we do to actively manage them to ensure that you will have minimal symptoms and not be a drain on precious medical resources?
There is a growing body of data showing that your risk of requiring hospitalisation, experiencing acute symptoms and death is correlated with your metabolic health.
The chart below shows the early data from the Chinese Centre for Disease Control and Prevention. While you can’t do anything to change your age and gender, there are things you can do to manage your health conditions. The common comorbidities primarily relate to your level of fitness and your body fat which ties back to your nutritional status.
Optimising Nutrition advisor Brian Lawenda has created this handy calculator that will help you calculate your risk of mortality if you are infected with COVID-19.
Sadly, our cheap and convenient but highly processed nutrient-poor modern diet has left us exposed to poor immune health and increased risk of the excessive inflammatory response that appears to lead to the more severe complications of COVID-19. Sadly, our default response in times of stress is to reach for processed comfort foods which tend to be cheaper for a range of reasons including existing government subsidies on large scale mono-crop agricultural food production.
Rather than experiencing annoying ‘flu-like symptoms’, it’s your metabolic health (and smoking) that seems to take it from a mild inconvenience to a life-threatening infection!
Data from a recent French study High prevalence of obesity in severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) requiring invasive mechanical ventilation showed the people presenting at the hospital were much more likely to be showing up with COVID-19 if they were obese.
And of those with COVID-19, people who were obese were also much more likely to require ventilation due to severe complications.
And, let’s just say you don’t want to end up needing ventilation.
The abstract of the study notes:
“The present study showed a high frequency of obesity among patients admitted in intensive care for SARS‐CoV‐2. Disease severity increased with BMI. Obesity is a risk factor for SARS‐CoV‐2 severity requiring increased attention to preventive measures in susceptible individuals.”
Professor Jean-François Delfraissy, who heads the scientific council that advises the French government on the COVID-19 pandemic, said
“This virus is terrible, it can hit young people, in particular obese young people. Those who are overweight really need to be careful. That is why we’re worried about our friends in America, where the problem of obesity is well known and where they will probably have the most problems because of obesity.”
Another recent paper from New York shows that people who are obese and sedentary tend to shed the virus for longer and experience a defective response in both the innate and adaptive immune system and hence should be quarantined for longer.
You shouldn’t try to “boost” your immune system (but you can support it)
Not surprisingly, there has been a steep increase in the interest in supplements and hacks to “boost” your immune system, with many people eager to buy pills and potions that will boost their immune system.
Unfortunately, while you can support and nourish a healthy immune system with food that contains a range of essential nutrients that nourish healthy immune function (e.g. adequate protein, vitamin D, vitamin A, vitamin C, potassium, zinc, iron, and selenium), you should be wary before trying to “boost” your immune system with isolated and concentrated supplements.
Check out our detailed breakdown of the nutrients that do the heavy lifting to support a healthy immune system in our previous article What to eat to support your immune system.
The severe symptoms of COVID-19 occur due to an overactive and imbalanced immune system response (known as the cytokine storm). Experts in the field (including Dr Chris Masterjohn and Chris Kresser) have warned about the risks of overdoing supplementation of critical nutrients such as vitamin A, D and C due to the risk of exacerbating the cytokine storm (i.e. the excessive immune response that makes COVID-19 deadly). Vitamin A and D play a crucial role in building more ACE2 receptors and increasing their expression, hence excessive supplementation can drive an overactive immune response.
What happens when you get COVID-19?
I know there has been a bit of doom and gloom in this post so far.
My overall intent is to give some action steps on what you can do to minimise your risk.
The good news is that it is likely that, for a lot of people, COVID-19 will be a non-event with minimal long term complications. Perhaps it will even be an anti-climax after all the fear that everyone has experienced over the past few months.
Again, we don’t know for sure. But I’m hopeful.
While I’m not encouraging you to go out and try to get your dose of COVID-19 now, if you are healthy and well-nourished, there is likely not a lot to be concerned about, particularly if your local hospital isn’t overflowing and is well stocked with personal protective equipment for their doctors and nurses.
Most people will likely stay at home and rest up until the temperature goes down. If you call your doctor it’s likely they will tell you to rest at home until it passes. There is not a lot you can do other than keep up the fluids and try not to spread the virus to others.
Hopefully, before too long you’ll be able to get a home antibody test kit to confirm that what you had was actually COVID-19.
Congratulations, you have now developed antibodies and can now get on with life without fear of being infected!
However, for some people, the acute inflammatory reaction affects their lungs and they have trouble breathing. If this is severe, they may need to go to the hospital for medical attention.
Where things get messy is when the infection and inflammation become severe (i.e. the cytokine storm).
While we don’t fully understand the mechanisms of COVID-19, we know that elevated blood sugars interfere with a healthy immune response.
Excessive levels of unhealthy body fat mean that you are likely to have high levels of inflammatory cytokines floating around in your body. These are beneficial at normal levels, but it’s the hyperinflation due to the overactive and imbalanced immune response where the symptoms become severe.
There are a number of schools of thought on why breathing becomes difficult:
- Firstly, people with more body fat tend to have a higher respiratory quotient (RQ) and tend to rely on their glucose metabolism (aerobic) and hence are more susceptible to being out of breath. Due to oxidative priority, your body has to burn off any excess glucose in your system before fat and we consume around 30% more oxygen when we burn carbohydrates compared to fat. If you are predominantly burning glucose because of a backup of excess fuel in your system, then you are more likely to use more oxygen regardless of COVID-19.
- For some, the infection in the lungs turns into severe pneumonia (known as Acute Respiratory Distress Syndrome or ARDS). Your lungs fill with water due to the excessive immune response and it becomes harder and harder to breathe. This is the point that you may be sedated and put on a ventilator. As noted earlier, the prognosis, once you get to this point, is not great. If you can’t avoid being exposed to COVID-19 (i.e. we don’t manage to eradicate it from the world), you should do everything you can to avoid being a patient who requires ventilation.
- There is another school of thought that the reduction in ferritin (i.e. iron) in the bloodstream that accompanies infection also leads to low oxygen levels that lead to the hypoxia (i.e. low oxygen levels and inability to breath).
- Elevated ferritin often accompanies inflammation (which is frequently seen in diabetes). While adequate dietary iron is critical to support healthy immune system function and many people (particularly in women) suffer from low iron levels, this also feeds on the iron, which can lead to low iron levels. Also, in an effort to combat the virus the body tries to remove iron from the blood to starve the virus of iron. Check out more discussion around this topic with Elizma in our Facebook Live chat here.
- According to another smart friend Robert Miller, declining NAD+ (i.e. Nicotinamide adenine dinucleotide) levels (that typically align with age and obesity) also play a key role in susceptibility to more severe symptoms of COVID-19. While consuming a diet with adequate niacin and other essential nutrients and not being overfat is enough for most people, it appears that there are plausible mechanisms that would support intravenous NAD+ in severe COVID-19 cases. We previously discussed how you can boost your NAD+ with diet in the article Can longevity be bought in a bottle? This detailed discussion is way beyond the scope of this article, but if you’re interested in checking out Robert’s thoughts on this and collaborating with him to explore further, you can check them out here.
What can you do to manage your risk now?
While many of us are currently bunkered away inside having hoarded processed comfort foods and stressed about the future, the best thing we can do to improve our odds when we are exposed to COVID-19 is:
- Get outside and see some sun (to boost your vitamin D and improve your circadian rhythm),
- Do what we can to be active and fit, and
- Eat in a way that will help you achieve a healthy weight and be well-nourished.
After four years of development and refinement, we recently released our series of 22 recipe books tailored to a range of goals. If you’re interested, you can learn more about the series of recipe books here and here.
Unfortunately, trying to sell recipe books in a pandemic is not a great business strategy, so we thought we’d release a free abridged version of our Immunity Book. This will give you access to the best recipes that provide more of the essential nutrients that will support a healthy and balanced immune function.
To get a free abridged version of our immunity recipe book with the recipes of the highest-ranking foods and recipes to support your CLICK HERE.
We hope you love it and it helps people prepare for the ‘interesting’ times and many unknowns that still lie ahead.
Finally, be kind
Finally, these are challenging times.
Our media is driven by sensationalism, conflict and controversy! And at the moment, there is more than enough of that going around!
It’s easy to lash out and point the finger and point out where something of someone else is wrong.
But we don’t do well when there is a lack of certainty! Our personal and collective mental health is stretched!
In times like this, we need to learn to be comfortable that there are things we don’t yet know and do what we can with the knowledge that we do have.
As we collaborate and share information we will have more certainty about our way forward. But for now, all we can do is what we can do to enjoy each day and try to make the world we live in a better place.
Be well. Stay safe. Be kind.