0

Category: Cardiovascular Disease (CVD)

What Physicians Need to Know About The Novel Coronavirus

As of March 19, 2020, there have been over 10,500 cases of confirmed novel coronavirus in the United States resulting in a total of 158 deaths. Currently the number of infected individuals  is relatively low in the U.S. compared with over 92,000 reported cases in mainland China since the first reported case in the country in November. However,  as the virus spreads, the number of COVID-19 cases outside of the epidemic epicenter is on the rise. Worldwide, the virus has led to the deaths of over 9,800 patients, most of whom have been older adults with underlying health conditions.

 The novel coronavirus has become a major public health concern across the globe, significantly impacting the populations of mainland China, South Korea, Italy, and Iran, while confirmed cases of COVID-19 have now been reported in the majority of countries across all continents. As more information is becoming known about the pathology of the new coronavirus, scientists and medical professionals will continue to share recommendations on how to best approach the the virus within the healthcare setting. The latest guidance for clinicians on coronavirus care can be found on the Centers for Disease Control and Prevention website.

 

COVID-19 Pathology & Severity

 As evidenced by the diverse outcomes of infected patients, symptoms of COVID-19 can vary widely. Some individuals may experience no symptoms at all, while most experience a local infection of the respiratory system akin to the common cold. Other symptoms can include fever, cough, and shortness of breath. Thus far, the majority of reported cases have been considered mild and mostly range from cold-like symptoms to mild pneumonia according to the latest data from the Chinese Center for Disease Control and Prevention.

Only a small percentage of COVID-19 patients gets severely ill, and even fewer experience fatal outcomes. According to the latest data, 14% of cases have been deemed severe – involving serious pneumonia and shortness of breath. Critical cases were identified in 5% of confirmed patients, who subsequently developed respiratory failure, septic shock, and/or multi-organ failure with potentially fatal outcomes which occurred in approximately 2.3% of cases. Currently, global medical and research communities are working to uncover more information on the pathology of the novel coronavirus and the reasons behind differences in severity among populations.

 

Demographics At Risk

According to the first large-scale study of COVID-19 , elderly patients may face an increased risk for serious illness associated with coronavirus, alongside individuals with chronic health conditions. While fewer than 1% of healthy patients with COVID-19 died from the disease, patients with comorbid conditions may experience poorer outcomes.

In those with cancer, hypertension, or chronic respiratory disease, mortality rates have been closer to 6%; patients with diabetes have a slightly higher risk at 7.3% and 10.5% for those with cardiovas. In contrast, the fatality rates for patients between 10 and 39 years old are about 0.2%; mortality in individuals between 40 and 50 years is currently 0.4% and 1.3% in those above the age of 50.

 

Researchers believe this could be a result of immune dysfunction that may lead to an uncontrolled immune system response resulting in pneumonia, severe lung damage, and in more severe cases, acute respiratory distress syndrome and septic shock – the primary causes of death in COVID-19 cases. Compounded by preexisting health conditions and poorer health, a weakened immune system in these patients ultimately heightens the risk of serious illness and adverse outcomes – all of which can be mitigated through self-isolation and appropriate sanitary procedures.

 

Comorbid Conditions

In the large-scale study of patients with underlying illnesses, Chinese researchers analyzed 1,590 patients with confirmed COVID-19 and examined how comorbidities affected the risk of poor outcomes – including the need for intensive care and ventilator administration as well as death.

Adjusting for age and smoking status, the study’s authors found that 399 patients with confirmed coronavirus and at least one other disease – cardiovascular disease, diabetes, hepatitis B, chronic obstructive pulmonary disease, chronic kidney diseases, and cancer – had a higher likelihood of requiring intensive care or a respirator or both, or of dying. The team concluded that comorbidities are present in about one fourth of patients with COVID-19 in China and likely predispose patients to poorer clinical outcomes.

Based on their observations, researchers believe underlying disease may change the progression of coronavirus. Causes of death included heart disease, stroke, and high blood levels of potassium implicating that the high fatality rate in patients with comorbid conditions may result from an exacerbation of underlying disease and not the virus itself.

Youth as a Protective Factor

Based on current data, it appears that children – especially those under the age of 9 – are not very susceptible to the virus. There have been very few cases of coronavirus in children and none have died. Individuals under 18 make up only 2.4% of all COVID-19 cases and in mid-January close to the height of the epidemic, zero children in Wuhan had contracted the virus. A potential explanation for youth as a protective factor in regions near the epicenter of the epidemic is that children are likely to be exposed to other coronaviruses, potentially giving them partial immunity to COVID-19. However, further investigation is required to conclusively determine why younger patients may be less affected by the virus.

Current Clinical Recommendations

While scientists are still investigating the exact pathology of the disease there is not yet any specific guidance for protection against the novel coronavirus for people with compromised immune systems or those afflicted with preexisting health conditions. Current population-wide recommendations emphasize the importance of frequent hand washing, not touching the face, and avoiding close contact with people who are sick. Experts also advise against utilizing face masks for virus protection, cautioning that they may have an opposite effect on risk aversion if not used properly.

In addition, the World Health Organization recently released interim guidelines for healthcare practitioners which recommend testing for COVID-19 in the presence of severe acute respiratory infection in patients who have either come into close contact with an infected individual or who have travelled to one of the Level 3 countries listed here.

It is important for physicians to educate and monitor the health of all of their patients, especially those considered at-risk, to ensure they are proactively protecting themselves against the rapidly spreading virus. Increasing precautionary measures and staying updated on the emerging clinical information can help both medical professionals and their patients actively work to limit transmission and prevent the development of further COVID-19 cases. 

Benefits of a Plant Based Diet in Keeping A Healthy Heart

Over the last decade, cardiovascular disease (CVD) has taken the form of a global epidemic, with an estimated 18 million deaths each year, making CVD the number one killer globally.* In the US, approximately 1 of every 3 deaths is due to some form of CVD like coronary heart disease (CHD), stroke, hypertension, or heart failure.* 

Even though these facts and figures paint a grim picture, the silver lining is that CVD is preventable. The key is to be aware of the risk factors and manage them for a healthy lifestyle; for example, an unhealthy diet, sedentary lifestyle, and heavy tobacco/alcohol usage can certainly be avoided or minimized to prevent cardiovascular events.

Currently, direct dietary counseling of CVD patients is still a challenge mostly due to lack of formal nutrition education among clinicians and the time required to convince patients to adhere to a specific diet.* Additionally, the abundance of information and controversies on food and food groups regarding optimal diet do not necessarily make it easy for people to decide what to eat.

Historically, countless epidemiological studies have highlighted the importance of diets in preventing CVD. They show how specific diet patterns—like eating plant-based foods, consuming foods with low saturated fat—reduce CVD incidence and severity.* In fact, diet changes are the biggest drivers of a healthy heart. Thus, almost all the guidelines now recommend that, along with adequate treatment, clinicians should actively incorporate evidence-based dietary counseling as part of cardiovascular therapies. 

As scientific research continues to shed light on the importance of diet and nutrition, perhaps the most critical questions that we face today are — What is an optimal diet? And how do we implement this optimal diet counseling in clinics? 

Nutrition research and evolution of the plant-based diet

Some of the earliest nutrition research (in the 1950s) highlighted the adverse outcomes of fat-enriched diet (mainly saturated fat) on heart diseases, giving rise to the widespread belief that fatty foods contribute to CVD.* Subsequently, the 1980 Dietary Guidelines for Americans focused heavily on isolated nutrients: “avoid too much fat, saturated fat, and cholesterol; eat foods with adequate starch and fiber; avoid too much sugar; avoid too much sodium”.* 

Soon after, in the 1970s, the Seven Countries Study, spearheaded by Ancel Keys, explored the association of diet and dietary habits with CVD incidence in populations representing seven different regions. The study design illustrated the influence of eating on the risk of CVD. It recognized the power of the plant-based diet, popularly known as the Mediterranean (MED) diet, in lowering cardiovascular mortality risk. Simply put, the MED diet entails — high intake of legumes, vegetables, fruits, and low consumption of dairy and meat (saturated fat), with fats mainly from nuts.* 

This ground-breaking study eventually inspired and prompted a slew of subsequent dietary research. DASH (Dietary Approaches to Stop Hypertension; 1997) and PREDIMED (Prevención con Dieta Mediterránea; 2018) are particularly noteworthy since they championed the idea of plant-based foods and the associated benefits to heart health. Similar to the MED diet, the DASH diet consists of a high intake of vegetables, fruits, whole grains, and olive oil with minimal consumption of red/processed meat, refined carbohydrates, and processed foods.

Adherence to the DASH diet resulted in a significant drop in heart failure risk among healthy adults (27% in men; 37% in women),* while a Mediterranean diet supplemented with extra-virgin olive oil or nuts lowered the incidence of major cardiovascular events among high-risk individuals.*

Diving deep into the plant-based diet

As of 2017, 6% of Americans claim to be vegetarians or vegans compared with just 1% in 2014.* The number is expected to rise in the coming years as more people become aware of the health benefits of the plant-based or vegetarian diet. 

A plant-based diet not only prevents risks of coronary diseases, but it also has multiple other health benefits that include improving gut microbiota and cognitive brain function. Plant-based foods are one of the richest sources of dietary fiber and essential phytochemicals and great for antioxidant vitamins, minerals, and micronutrients.

Despite being universally accepted as heart-healthy, wholesome, and nutritionally superior to animal products, plant-based foods are considered protein poor by many. The long-standing belief is that plant-based proteins are incomplete because they don’t have all the essential amino acids that humans need. However, growing evidence from research work is breaking this myth.

Citing the research work of William Rose and team, John. A. McDougall, an American physician and author, states that: “A vegetarian diet based on any single one or combination of these unprocessed starches (e.g., rice, corn, potatoes, beans), with the addition of vegetables and fruits, supplies all the protein, amino acids, essential fats, minerals, and vitamins (except vitamin B12) necessary for excellent health”.*

Christopher Wharton reviewed various research works that show how a plant-based diet is on par with the omnivorous diet in supporting athletic performance and strength among recreational athletes.* Recently, Novak Djokovic, the Serbian tennis legend, credited his plant-based diet as the secret to his remarkable recovery after injury.

Because nutrition is the cornerstone of human health, the role of a physician is crucial than ever in educating patients about positive dietary changes to improve their health and wellbeing. It’s about time that the wealth of scientific knowledge in favor of plant-based diets makes its way into the clinical care regimen, and clinicians incorporate diet communication along with pharmacotherapy.

Contributed by:

Sangeeta Chakraborty Ph.D 
Associate Researcher,
National Jewish Health,
Greater Denver Area, Colorado

*References:

  1. World Health Organization. Newsroom-Fact sheets (2017).
  2. American Heart Association. “Heart disease and stroke statistics 2018 at-a-glance.” on-line at: http://www. heart. org/idc/groups/ahamahpublic/@ wcm/@ sop/@ smd/documents/downloadable/ucm_491265. pdf (2017).
  3. Storz, Maximilian Andreas. “Is There a Lack of Support for Whole-Food, Plant-Based Diets in the Medical Community?.” The Permanente Journal 23 (2019).
  4. Ravera, Alice, et al. “Nutrition and cardiovascular disease: Finding the perfect recipe for cardiovascular health.” Nutrients 8.6 (2016): 363.
  5. Kerley, Conor P. “A review of plant-based diets to prevent and treat heart failure.” Cardiac failure review 4.1 (2018): 54.
  6. Page, Irvine H., et al. “Atherosclerosis and the fat content of the diet.” Circulation 16.2 (1957): 163-178.
  7. Davis, Carole, and Etta Saltos. “Dietary recommendations and how they have changed over time.” America’s eating habits: Changes and consequences (1999): 33-50.
  8. Keys, Ancel. “Diet and the epidemiology of coronary heart disease.” Journal of the American Medical Association 164.17 (1957): 1912-1919.
  9. Keys, Ancel. “Coronary heart disease in seven countries.” Circulation 41.1 (1970): 186-195.
  10. Appel, Lawrence J., et al. “A clinical trial of the effects of dietary patterns on blood pressure.” New England journal of medicine 336.16 (1997): 1117-1124.
  11. Estruch, Ramón, et al. “Primary prevention of cardiovascular disease with a Mediterranean diet supplemented with extra-virgin olive oil or nuts.” New England journal of medicine 378.25 (2018): e34.
  12. Data, Global. “Top Trends in Prepared Foods 2017: Exploring Trends in Meat, Fish and Seafood; Pasta, Noodles and Rice; Prepared Meals; Savory Deli Food; Soup; and Meat Substitutes.” June. Available online: https://www. reportbuyer. com/product/4959853/top-trends-in-prepared-foods-2017-exploring-trends-in-meatfish-and-seafood-pasta-noodles-and-rice-prepared-meals-savory-deli-food-soupand-meat-substitutes. html (accessed July 29, 2017) (2017).
  13. McDougall, John. “Plant foods have a complete amino acid composition.” Circulation 105.25 (2002): e197.
  14. Lynch, Heidi, Carol Johnston, and Christopher Wharton. “Plant-based diets: Considerations for environmental impact, protein quality, and exercise performance.” Nutrients 10.12 (2018): 1841.