Focus on Obesity to Mitigate COVID Risk

The COVID pandemic has clearly underscored the consequences of another American health crisis: the obesity epidemic. And it further emphasizes the necessity for integrating sustainable lifestyle practices that promote general health and wellbeing.

In a sense, COVID tells a tale of two pandemics: one infectious, and one chronic and longstanding.

The SARS-CoV-2 virus has permeated our everyday life for two years now, and many of our patients have had drastic changes in their lifestyles as a result. Community activities shut down, gyms closed, and many people became more sedentary. A lot of people started working from home, thus reducing their already minimal daily walking and movement. Even shopping has shifted online, and many people need only walk from the couch to the front door or the curbside to pick up their deliveries.  

Putting it simply, the pandemic has rendered many of us inactive, which is furthering our already alarming obesity rate. And we know that obesity and its related metabolic disorders are major COVID risk factors.

The CDC reports that in 16 of the 50 states, 35% or more of all residents are now obese. That’s up from 2018, when 9 states had a 35% prevalence. A CDC-sponsored study of more than 540,000 hospitalized patients hospitalized showed that COVID-19 was linked to underlying conditions such as obesity, diabetes with complications, and anxiety disorders were the strongest risk factors for severe COVID and death.

What we have here is a vicious cycle: Obesity predisposes people to a severe COVID, but strategies aimed at preventing transmission of infection (work from home, online shopping, shuttering of social and recreational activities) promotes obesity.

To help our patients navigate this tumultuous time, we need to address both of these pandemics, and teach people about lifestyle factors that can reduce the risk of both.  

Here are five sustainable ways for your patients to transform their health, maintain a healthy weight, and support their immune system.

High-Protein Breakfast: Patients often come to us for dietary guidance. One of the best pieces of advice we can share is to eat a higher protein breakfast.

A 2015 study of 28 overweight but otherwise healthy adolescents showed that eating a daily breakfast containing at least 35 grams of protein, can reduce 24 hour glucose variability, daily glucose peaks, and post-prandial glucose fluctuations (Bauer LB, et al. Int J Obes. 2015). It improves overall glucose control, thereby helping people maintain or work toward health weight.

Of course it is also important to minimize fast foods, processed foods, and products laden with added sugars, artificial sweeteners, and trans fats.

Physical Activity: Working out is an excellent way to lower obesity in the population. I believe it is part of our job as physicians to make sure that our patients engage in a workout routine of some sort that they enjoy and that won’t lead to fatigue or injury.

The American Heart Association recommends that healthy adults get 150 minutes (30 minutes, five days a week) of aerobic activity. This is easily accomplished with a 30-minute walk after dinner. If someone can’t walk for 30 minutes straight, break it out into three 10-minute walks, or two 15-minute walks.

If a patient has been completely sedentary, it’s best to ease into physical activity rather than immediately jumping into an intensive routine. The main thing is to get people moving. Moderate exercise is crucial during this prolonged pandemic.

A recent Kaiser Permanente analysis of data from more than 48,000 COVID patients showed that those who were routinely inactive had significantly higher risk for severe Covid-19 outcomes (hospitalization, ICU admission, death) than those who consistently met basic physical activity guidelines (Sallis R, et al. Br J Sports Med. 2021).

Optimize Sleep: The CDC recommends that adults aged 18-60 years get seven or more hours of sleep per night. The reality is that our patients might be sacrificing sleep to accomplish other goals such as work, social or familial responsibilities.

Sleep is essential for physiological and neurological rest and repair. It also plays a central role in maintaining healthy weight and sleep deprivation impedes the ability to lose weight.

University of Chicago researchers showed that people sleeping 8.5 hours lost 55% more body fat than those sleeping an average of 5.5 hours, while following exact same moderately restrictive diet (Nedeltcheva AV, et al. Ann Intern Med. 2010).

Keep in mind that lack of sleep or burnout may increase risk of Covid-19 infection, so proper sleep is a key factor not only for reducing risk of obesity, but also for staving off SARS-CoV-2 and other viruses as well.

Reduce Exposure to Obesogens: Obesogens are synthetic chemicals that disrupt the endocrine system and lead to weight gain and obesity. Many of these compounds also hinder the body’s natural immune response. They are being let loose at astonishing rates into our environment. According to an excellent summary on the website Seeker.com, worldwide there are 10 million new chemicals released each year, which is more than 1,000 per hour. Only a tiny percentage of them have been studied in terms of their ecological and physiological impacts.

More than 20 chemicals have been identified as obesogens, many of which are estrogenic in that they easily bind to estrogen receptors. The  five obesogens most commonly found in the home are Bisphenol-A (BPA), Phthalates, Atrazine, Organotins, and Perfluorooctanoic Acid (PFOA).

Reducing exposure to these chemicals is as simple –or as complex—as paying attention to the types of personal care, cosmetics, and household products one purchases. Choosing the ones that are free from some or all of these compounds. It is also wise to minimize the use of plastic containers for food storage or preparation, since plastics are a major source of obesogenic substances. Glass, stainless steel, and ceramic options abound, and they are much safer.

Optimize Vitamin D Levels: For overall health improvement, this is one of the easiest changes to implement. Taking a vitamin D supplement is a completely sustainable habit that can have a tremendous impact on patient health, especially for people living in northern latitudes that do not get as much sun exposure.

There’s ample evidence that low vitamin D correlates with high COVID risk. A study from the first year of the pandemic showed that vitamin D deficiency was associated with a six-fold increase in severe disease from COVID-19 and 15-fold risk of death, so this is a healthful, timely and easy resolution (Radujkovic A, et al. Nutrients. 2020). Since then, many other studies have been published, from all over the world, showing this inverse correlation.

Beyond vitamin D, many other nutrients can be helpful for immune system support. Getting a better snapshot of your patient’s immune system can help you to tailor your suggestions. Cyrex Laboratories, a clinical laboratory specializing in functional immunology and autoimmunity, has developed a test panel called the The Lymphocyte MAP™.

The Lymphocyte MAP screens the integrity of the immune system to define a patient’s immune status and immunotype(s) based on 29 key biomarkers and determinants. It tells you a lot about the current status of a patient’s immune system so that you can provide guidance on adjustments that will bolster immune response.

As the COVID-19 pandemic continues to surge, this can be vital information as we work to help our patients fight not only the virus, but the broader pandemic of obesity and metabolic dysregulation. 

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Dr. Chad Larson, NMD, DC, CCN, CSCS, Advisor and Consultant on Clinical Consulting Team for Cyrex Laboratories. Dr. Larson holds a Doctor of Naturopathic Medicine degree from Southwest College of Naturopathic Medicine and a Doctor of Chiropractic degree from Southern California University of Health Sciences. He is a Certified Clinical Nutritionist and a Certified Strength and Conditioning Specialist. He particularly pursues advanced developments in the fields of endocrinology, orthopedics, sports medicine, and environmentally-induced chronic disease.

Preparing Patients for This Winter’s “Twindemic”

As we head into the peak months for the flu, we as health care providers need to be especially vigilant about the integrity of our patients’ immune systems. Paired with COVID-19, this year’s flu season carries the serious risk of compromising their future immune response. 

A key step in preventing these complications lies in helping our patients understand the strengths and weaknesses of their immune systems. Being more aware of their individual vulnerabilities will equip them with an additional line of defense during the dangerous winter months.

With advanced tools like immunophenotyping, we will be better able to advise patients about ways to protect themselves against the threat of serious illness.

Because widespread social distancing and mask measures brought about an historic decrease in influenza transmission last year, population immunity is also likely to be lower than it has been.

A Brutal Flu Season

This year’s flu season is anticipated to be particularly severe, and with COVID-19 still spreading in communities across the country, the stage is set for an impending “twindemic.”

Because widespread social distancing and mask measures brought about an historic decrease in influenza transmission last year, population immunity is also likely to be lower than it has been, according to the Centers for Disease Control and Prevention (CDC) and National Foundation for Infectious Diseases (NFID). As such, everyone is at increased risk of contracting the flu during the 2021-22 season.

Even in milder years, the flu has a significant impact on hospitalization and mortality rates. According to the CDC’s estimates based on preliminary data from the 2019-20 season ending just prior to broad adoption of COVID-19 precautions, there were approximately 35 million people with symptomatic illness, 380,000 hospitalizations and 20,000 flu-related deaths in the US.

With the flu and COVID-19 both circulating and potentially peaking simultaneously in early winter, a large population of the country is under high risk of co-infection. This can not only aggravate the symptoms and complications of disease, but also create treatment conflicts for individuals who are hospitalized.

For example, corticosteroids, administered to prevent or mitigate severe COVID-19-related inflammatory responses, are associated with poor outcomes and increased mortality in severe influenza patients.

Assessing the Immune System

With both viruses triggering immune responses that affect vital organs, including the lungs, brain, heart, and muscle, we are concerned about the long-term risks that co-infection brings to the immune system.

We know that people with weakened immune systems due to preexisting disease or exposure to certain medications are at a higher risk for complications from both the flu and COVID-19.

Recent research has also shown the ability of SARS-CoV-2 to hyperstimulate the immune system and trigger flares of pre-existing autoimmune reactions, even among those who previously showed no overt symptoms of autoimmune disease. Many of our patients could unknowingly be immunocompromised and at risk of severe illness in the event of co-infection this flu season.

With the flu and COVID-19 both circulating and potentially peaking simultaneously in early winter, a large population of the country is under high risk of co-infection.

A complete blood count (CBC) done as part of routine blood work, is frequently the initial diagnostic tool for identifying immunological disorders. But it is only a small part of a complex map that helps our patients understand their immune systems and potential weaknesses.

CBCs alone are insufficient and incomplete for helping us determine how vulnerable our patients are to opportunistic viruses. Looking at a patient with an inflammatory disorder, for example, white blood cell (WBC) and total lymphocyte counts could both come back as “normal” on a routine CBC, indicating nothing out of the ordinary, despite the fact that the patient is actually suffering from dysregulation of the immune system.

In fact, most immunologists agree that even in patients who have been diagnosed with immune-mediated conditions like allergies, rheumatoid arthritis, and neuropathies, the CBC is normal about 70 percent of the time.

Immunophenotyping for Flu Protection

Being able to detect early immunological warning signs and risk goes a long way in helping patients understand the functions and responses of their immune systems. We can offer this support by looking at immunophenotype patterns, or immune system “fingerprints,” which paint a much clearer picture of immunological makeup.

Immunophenotyping provides critical information about immune cells and how well they work together. The techniques are based largely on flow cytometry, which isolates and quantifies different types of cells based on antigens and markers present on the cell surface. Advanced flow cytometry can precisely measure the properties of living cells such as size, shape, density, and granularity, with a high degree of precision.

Lymphocytes represent 20% to 40% of a patient’s total WBCs. By quantifying these subpopulations and the ratios between them, we are better able to predict how an individual might react to environmental antigens like influenza viruses.

Immunophenotyping by flow cytometry is useful in the identification and quantification of lymphocyte subsets. This is especially valuable when working with patients whose CBCs are normal. Immunologists have found that about half of those with normal CBC values will show immune abnormalities when flow cytometry is used to quantify T-cell, B-cell, NK cell, CD4, and CD8 lymphocyte populations.

Flow cytometry is widely used in cancer research. The accuracy and detail provided by these tests have demonstrated significant value well beyond oncology.

Lymphocytes represent 20% to 40% of a patient’s total WBCs. By quantifying these subpopulations and the ratios between them, we are better able to predict how an individual might react to environmental antigens like influenza viruses.

Comprehensive Immunophenotyping

Knowledge gained through immunophenotype patterns is essential for physicians wishing to offer better immune system support, including helping immunocompromised patients make informed decisions during critical periods like flu season.

Cyrex Laboratories, a clinical laboratory specializing in functional immunology and autoimmunity, has recently developed a proprietary test panel called The Lymphocyte Map – Comprehensive Immunophenotyping of Lymphocytes. This tool provides a much more comprehensive evaluation of the immune system than a CBC, providing greater clinical insight about a patient’s immune susceptibility.

By measuring the integrity of the immune system at the cellular level, based on 29 key biomarkers, The Lymphocyte Map allows providers to classify a patient’s immunophenotype patterns into 13 different immunotypes. This can reveal hidden patterns and trends regarding immune system weaknesses, imbalances, and overall fitness.

Practitioners can also use immunophenotypes to design treatment plans to reduce or prevent the progression of disorders and mitigate the influence of exogenous pathogens.

Now, more than ever, this remains a critical component of patient care in the face of this season’s looming twindemic.

Chad Larson, NMD, DC, CCN, CSCS, holds a Doctor of Naturopathic Medicine degree from Southwest College of Naturopathic Medicine and a Doctor of Chiropractic degree from Southern California University of Health Sciences. He is a Certified Clinical Nutritionist and a Certified Strength and Conditioning Specialist with particular interest in advanced developments in the fields of endocrinology, orthopedics, sports medicine, and environmentally-induced chronic disease. Dr. Larson is an Advisor and Consultant on the Clinical Consulting Team for Cyrex Laboratories.

Mark Engelman, MD, is the Director of Clinical Consulting for Cyrex Laboratories. He is also the Founder and President of the Engelman Health Institute. His career history includes 23 years as the director of St. Joseph’s Medical Center emergency department; and a term as President of the Maricopa County American Heart Association. He is also the Founder and CEO of AmeriMed American Hospitals in Mexico; and is known as an expert speaker on emergency medicine both nationally and internationally.

Immune System “Fingerprinting” A Key to Understanding Autoimmunity

A recent study published in the journal Arthritis and Rheumatology, shows that the prevalence of antinuclear antibodies (ANA)– the most common biomarker of autoimmunity–has increased considerably in the United States in recent years.

Researcher Gregg E. Dinse and colleagues at Social & Scientific Systems, Durham, NC, examined the prevalence of ANA positivity in human subjects from three distinct time periods between 1988 and 2012. In total, they had data from 14,211 individuals.

The findings were astounding. Based on their sample population, they estimated that:

· In 1988-1991, 11% of the US population, or 22 million individuals, were ANA-positive.

· In 1999-2004, this increased to 11.5%, or 27 million individuals.

· In 2011-2012, the number was 15.9%, or 41 million individuals.

The authors note that prevalence of ANA increased in both genders over the last 30-plus years, but particularly in men. There were also marked increases in adults aged 50 years or older of all racial and ethnic backgrounds, and in non-Hispanic whites (Dinse GE, et al. Arthr Rheumatol. 2020).

“These increases in ANA prevalence were not explained by concurrent trends in weight (obesity/overweight), smoking exposure, or alcohol consumption,” they write.

As a category, “Autoimmune Disease” includes over 100 debilitating conditions; it is no wonder so many people are affected. The article also emphasizes the need for clinicians to take a more comprehensive look at the individual, immune system “fingerprints” of patients with autoimmune conditions. 

Immunophenotyping

The immune system “fingerprint,” or “immunophenotype” as it is known in research terms, reflects an individual’s immunologic makeup, and it has significant implications in terms of how the immune system functions both in relation to the body’s own tissues, as well as in response to exogenous pathogens.  

Immunophenotyping uses highly specific antibodies to identify various types of cells based on the antigens and markers expressed on their surfaces, in their nuclei, or in their cytoplasm. These techniques, based largely on flow cytometry, are widely used in basic immunological research, as well as in cancer research and oncology practice. They’ve enabled oncologists to identify and categorize certain types of cancer, particularly leukemias, with great accuracy.

The immune system “fingerprint,” or “immunophenotype” as it is known in research terms...informs how each individual may react, or is reacting, to an environmental antigen, like a virus. In the context of the COVID-19 pandemic, this sort of information is essential to helping immunocompromised patients protect themselves.

Flow cytometry utilizes light-scatter technology to detect and count specific cell types present in a mixture of cells. It is preferred by top researchers because of its quantitative accuracy and specificity.

Recently, however, interest in the technique has extended well beyond basic research labs and oncology centers.

That’s because these tests can give physicians much more detailed information about a patient’s immune system than we can obtain from standard Complete Blood Count (CBC) panels. We can gain unprecedented, in-depth views of our patients’ immune systems. This knowledge is critical to making informed clinical decisions.

Relevance for COVID Risk

Immune system fingerprinting has relevance to the current COVID-19 pandemic.

We know that patients with autoimmune diseases are at higher risk for COVID-19. According to the Global Autoimmune Institute, there are instances in which having an autoimmune disease increases vulnerability to COVID-19 complications. In other cases, contracting COVID-19 triggers pre-existing autoimmunity, leading to symptom flares. Severe cases of COVID-19 have been associated with hyperactive immune responses in chronically ill patients, as well as those who previously showed no signs of autoimmunity.

A pre-existing, but possibly undetected issue with the immune system may enable the SARS-CoV-2 virus to move from the nose and throat, into the lungs, and to spread to other parts of the body.

Immunocompromised patients may not be able to manufacture the antibodies needed to prevent the virus from entering cells. Likewise, individuals on immunosuppressive medications such as corticosteroids are also at higher risk to be infected and suffer more severe COVID-19 complications.

We live in an ever-changing world of complicated novel pathogens, such as COVID-19. While it is important that we research and understand each of them, we must also recognize that there is much more to the complex picture of an individual patient’s risks and outcomes.

Simplifying a Complex Picture

As Hen-Avivi and Avraham note in their 2018 paper, “There is, in fact, great heterogeneity in infection outcome, from complete clearance of the pathogen to severe illness. Understanding this variation remains elusive, despite its great potential to equip us with new tools for the treatment of infectious diseases.”

A pre-existing, but possibly undetected issue with the immune system may enable the SARS-CoV-2 virus to move from the nose and throat, into the lungs, and to spread to other parts of the body

They propose that single-cell analysis technologies and recent advances in single-cell RNA-seq technologies “allow the detection of rare subpopulations that play important roles in host-pathogen interactions.”  These techniques can provide “a ‘fingerprint’ of the immune cell types that are associated with the ability of the host to clear a pathogen and, thereby, broaden our current understanding of variation in susceptibility to infection within the population.” (Hen-Avivi S, Avraham R. Curr Opin Microbiol. 2018).

In the clinic, immunophenotyping can give us a lot of information about the integrity of a patient’s immune systems. It goes far beyond what we can obtain from standard lab tests, which are not specific-enough or sufficiently detailed to allow a thorough evaluation of a patient’s overall immune system health or the risks of future diseases and complications.

Beyond the CBC

For example, unusually high or low white blood cell (WBC) counts obtained from a complete blood count (CBC) may indicate that something is wrong, but they do not usually reveal what is going on with the patient. Often, a CBC comes back absolutely normal, but the patient could actually be suffering from immune system dysfunction, immunodeficiency, hyper-inflammation, autoimmunity, allergies, and hypersensitivities induced by environmental triggers.

Simply stated, a stand-alone CBC panel is only one piece of the puzzle. Tests that reveal various immunophenotypes can give us significantly more usable clinical information.

Flow cytometry actually separates and quantifies different types of cells by detecting unique markers present on the cell surface. It is much more specific than standard tests that attempt to quantify different immune cell types by measuring cellular products such as cytokines and other signaling substances.

Since lymphocytes make up 20-40% of an individual’s total white blood cells (WBCs), understanding the lymphocyte sub-populations (like TH1, TH2, CD4, CD8, TH17, Natural Killer Cells etc.) and their ratios is the foundation of a detailed immune system fingerprint.

This fingerprint informs how each individual may react, or is reacting, to an environmental antigen, like a virus. In the context of the COVID-19 pandemic, this sort of information is essential to helping immunocompromised patients protect themselves.

Cyrex Laboratories’ a clinical laboratory specializing in functional immunology and autoimmunity, has recently developed a proprietary test panel called The Lymphocyte Map – Comprehensive Immunophenotyping of Lymphocytes, that provides comprehensive information on an individual’s unique immune system fingerprint. The Lymphocyte Map is the latest release in Cyrex’ innovative line of tests geared toward assessing “immune health.” In essence, it translates a host of complex flow cytometry data into an immune health analysis report.

Given the wide prevalence of autoimmune conditions, and the ways that autoimmunity heightens risk for infectious diseases, it makes good clinical sense to consider running a Lymphocyte Map any time you would typically order a CBC. It can provide indispensable information for guiding treatment decisions, and it has the added benefit of helping practicing clinicians to better read and comprehend the current medical literature at a time of unprecedented interest in the immune system.

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Chad Larson, NMD, DC, CCN, CSCS, holds a Doctor of Naturopathic Medicine degree from Southwest College of Naturopathic Medicine and a Doctor of Chiropractic degree from Southern California University of Health Sciences. He is a Certified Clinical Nutritionist and a Certified Strength and Conditioning Specialist with particular interest in advanced developments in the fields of endocrinology, orthopedics, sports medicine, and environmentally-induced chronic disease. Dr. Larson is an Advisor and Consultant on the Clinical Consulting Team for Cyrex Laboratories.

Mark. Engelman, MD, is the Director of Clinical Consulting for Cyrex Laboratories. He is also the Founder and President of the Engelman Health Institute. His career history includes 23 years as the director of St. Joseph’s Medical Center emergency department; and a term as President of the Maricopa County American Heart Association. He is also the Founder and CEO of AmeriMed American Hospitals in Mexico; and is known as an expert speaker on emergency medicine both nationally and internationally.