Covid Corrections Part 1

Sorry I have been quiet recently. As the official Covid-19 death toll ticks towards half a million, with the real figure no doubt way beyond that already (unless you believe Russia’s claims about their superior healthcare system, and discount the curiously high rates of pneumonia deaths in several US states), it is hard to write anything about food right now that feels relevant or appropriate. 

That said, there is no doubting that the UK food system has done remarkable things over the past few months. People I had barely noticed before have shown extraordinary courage, innovation and resilience. Many factories have broken productivity records, whilst at the same time having to completely rework their production manuals to comply with social distancing guidelines.  Thousands of food industry workers woke up every morning whilst the world slept in, risking their lives as a pandemic swept the country. Many worked double shifts in shitty, back breaking conditions to keep the wheels turning, often on little more than minimum wage. Across the industry, there were many reports of PPE shortages as it became near impossible to procure, leaving workers unprotected and exposed. Most just got on with it. Many died. Every day the food industry press carries reports of new factory outbreaks and worker deaths. In the US meat industry alone, 25 thousand have been infected and nearly one hundred have lost their lives. Countless more will have to live with the pain of knowing that they infected vulnerable family members or loved ones.

In the retail sector, supermarket workers turned up with a smile, risking their own and their family’s health, just so we could buy soup and pasta. Sections of society that we have ignored or even mocked as low skilled and low value have pushed themselves to the limit, quickly becoming the backbone of this country. Staff have frequently shrugged off abuse, anger and vitriol, with extraordinary dignity and restraint. The food retail sector has led the way for hundreds of other businesses, forging a path to recovery, showing the world how to adapt. At every turn, workers risked their lives without complaint, somehow keeping the shelves stocked whilst the way they operate was completely redesigned around them.

The food industry kept us fed, but more than that, it kept us safe. A stocked supermarket, or a plentiful online order gave us a semblance of normality, a reminder that the world continued to turn, even though we were locked in our homes. If, as many predicted, our food system had failed or faltered, things would have become very dark, very quickly. We are only ever five meals away from rioting in the streets. Thousands of people risked everything to make sure this didn’t happen.

Health care and research are where the fiercest battles are fought against this virus, but it has been the food industry, from agriculture, to logistics, to manufacturing, to retail, that has held the country together. I am frequently attacked and vilified for my links to that industry, but I have never been so proud to work within it, and to count many of its unsung heroes as friends and colleagues.

So imagine my surprise to find out that Covid-19 was actually the food industry’s fault. Not according to some fuckwit like Mercola, or even his close friends Noakes, Malhotra and Harcombe, but in an opinion piece in the BMJ, reported in almost every newspaper. According to the article –

‘It is now clear that the food industry shares the blame not only for the obesity pandemic but also for the severity of covid-19 disease and its devastating consequences.’

Their logic is thus. The food industry made us fat, fat people are uniquely susceptible to Covid-19, therefore the food industry is responsible for thousands of deaths. Case closed. Naughty food industry. I am sure everyone would be far healthier if it didn’t exist.

There are a couple of things that trouble me about this. Firstly, although I do think that many aspects of the food industry are problematic, the whole idea of casting it as a single entity and blaming for obesity is a vast oversimplification of deeply complex, systemic issues. I am not going to cover this here because it would take too long, but I have written extensively about it in the past. 

The second troubling thing is the implicit assumption that obesity has made the severity of Covid-19 far worse. Although this now seems to be widely accepted in the press and within academic journals, it also feels deeply like a problematic oversimplification. Is obesity really making Covid-19 more severe? Are people at greater risk if they are carrying around a bit of body fat?  

A couple of years back I wrote a book… 

Do you mean the award winning ‘The Truth About Fat’, published by Oneworld and available from all good online retailers? The one that was Book of the Week in the Times, described as ‘a thought provoking corrective’ in the TLS, got a positive review in Nature, then was slagged off in The Guardian when they let someone with a grudge against us review it?

...about the complex relationship between health and obesity. The key thing that I learnt whilst researching was that although it fits a convenient and societally endorsed narrative that fat always equals unhealthy, whenever you look closely at that relationship, things always turn out to be way more complex than they first appear. Although it is apparently a controversial thing to say, there is surprisingly little evidence linking the amount of body fat someone stores with poor health outcomes, and so many confounding factors that it is almost impossible to pick apart. 

For instance, if someone loses weight through sensible exercise and dietary change, they are likely to see improvements in many markers of health. But if you suck out the same amount of fat through a liposuction straw, you do not see any corresponding health improvements at all, which is why this treatment is not recommended. And if you make the same lifestyle changes regarding diet quality and exercise but don’t happen to see any weight loss, your health is still likely to improve in much the same way. So is it the loss of fat mass that makes you healthier, or the change in behaviour? Logic would lean towards the behaviour, but the world, the media and countless diet gurus always blame the fat. 

As I discovered whilst writing my book, the real Truth About Fat is that as a society, we really hate looking at fat people. If we can claim that their fat is killing them, then we are free to insult and abuse them under the guise of concern. We can justify out nasty playground bullying with some faux-compassion, creating one of the last societally endorsed prejudices of our age. 

Hatred of fat bodies is so engrained that many public health professionals and health care providers will ignore their usual standards of evidence to maintain it. It has been known for many years that the BMI range currently known as ‘normal’ is associated with higher risk of death than that considered ‘overweight’, and comes with roughly the same risks as the one currently classed as type I obesity. Yet there has never been a push to get this built into public health guidelines, and barely a mention of this so-called ‘obesity paradox’ in the media. The question that you really have to ask is why it is considered a paradox? The BMI cut-offs for normal, overweight and obese were only ever arbitrary lines in the sand, largely based on 1950s insurance industry data. Why is it so surprising to us that our aesthetic preferences don’t always match desired health outcomes? 

Anyone challenging the fat-is-bad consensus gets slagged of in the Guardian, ostracised by the UK Food writing community, and told they are a clueless, politically correct loon peddling pseudoscience. Of course being thin is healthy, they say. Just look at all those healthy thin people in that gym over there. If they weren’t all on restrictive diets, taking steroids, necking slimming pills and developing dysfunctional relationships with food, they would be a picture of health and vitality.

(if you want references for these claims, buy my extensively referenced book you tight fuckers, I’m not here to do your homework for you).

So I have been surprised, and occasionally shocked, at the direct lines being drawn between obesity and Covid-19 deaths during this pandemic. Can it be that in this particular case, excess body fat is causing so many extra deaths? Is Covid-19 so prevalent and deadly in countries such as the UK and US because of our higher rates of obesity? Did Boris Johnson suffer more from Covid-19 than his government colleagues because of his higher BMI? Are fat people more likely to contract the disease and more likely to die? 

The newspaper reporting has left us in little doubt. Here are some headlines –

Dad Says Daughter, 24, Died of Coronavirus Because She was Morbidly Obese – The Metro

Boris Johnson to Launch Anti-Obesity Drive After Coronavirus Scare – The Express

Boris Johnson is the Proof That You Cannot be Fat and Fit – The Daily Mail

Obesity and Coronavirus – How can a higher BMI increase your risk? The Guardian

The Guardian article contained extensive quotes from bariatric surgeons, claiming that their particular butchery specialism was the short cut the world needs to stop everyone from dying. Right now, in their completely unbiased opinion, the ideal public health strategy is to check fat people into hospitals, slice up their insides, and watch the numbers fall. I suppose I shouldn’t be surprised a national news outlet gave voice to this opinion, but this one even shocked me a little.

When I started to ask questions about this coverage, Captain Science awoke from her slumber and started to get very fucking cross. Because surprise, surprise the truth about Covid-19 and fat is not at all that it seems. Despite extensive media coverage, government rhetoric, and many features written by supposedly responsible academics, if we are after a modifiable risk factor for Covid-19, once again, fat is not the place we should be looking.

Firstly, let’s look at where all this is coming from. We are in the middle of a rapidly evolving situation and good quality evidence is really hard to come by. The most extensively referenced paper in the media was one that looked at NHS data, which did show a slightly increased risk of dying for people with a BMI between 30 and 35, and an even greater risk for BMIs over 40. Although this data was taken from a point when the UK only had around six thousand deaths, and things may well have changed, it does seem to support the idea that overweight people are at greater risk.

Really? Are you sure? For a start, it did not include any BMI groups under 30, which, in my opinion shows an intrinsic bias. So how the fuck do you know anything about the overweight group?

Hello Captain Science. It’s been a while. How have you been?

Whatever. No time for fucking small talk. They use a BMI of below 30 as the reference range, which seems stupid to me. If you look at the raw data, the percentage of underweight patients who died is the same as the percentage of obese and category 2 obese patients (0.05%). The lowest percentage of deaths in a BMI category is normal (20-25), then overweight (25-30). The highest is over 40 (0.06%), but that’s not really surprising if hospitals are short staffed and the standard of care is compromised, because those patients can require more staff for proning and the like. 

There are a few other studies that have made headlines. A French study found that people with a BMI over 35 were more likely to be put onto a ventilator. A CDC report from the US found that for those with BMI data, 48% were in the obese category, compared with 42% from the US as a whole.  Yet neither of those reports controlled for race, social economic group or access to healthcare, all things that are likely to confound results. 

Perhaps even more importantly, early communication about the increased risk for overweight and obese patients may well have led to health disparities. In the US, obesity was listed as a risk factor seemingly before any evidence supported it. Certainly none of the early reports coming out of China mentioned it as a factor. Because of this early listing, it is likely that many obese patients will have been more likely to be given intensive treatments. A New York study found that obesity increased the risk of hospitalisation, but was not a factor in the development of critical illness. 

Yeah, it’s a complicated fucking mess to be honest. There isn’t much data, and hardly any of it is reliable. Not sure how everyone is so certain about the obesity thing. The French study is most likely just a product of the horrendous fat prejudice in that country. And almost all the studies set ‘normal’ weight as a HR of 1, which shows how much bias there is towards obesity. It’s particularly fucking weird, because obese patients typically do better with ARDS than underweight, or even those with ‘normal’ BMI, so you would at least expect a record of underweight patients.

ARDS?

Sorry, I forget I have to explaining every fucking thing to you in easy words. Acute Respiratory Distress Syndrome. It has been shown in the past that people with BMIs over 30 have a significantly lower risk of dying. Also, studies of non-Covid ICU patients on mechanical ventilation show that a higher BMI is associated with lower mortality, which is probably not what most people would expect. So the fact that none of the studies even record underweight patients shows how much bias exists.

I know what an ICU is.

Whoopdy fucking do, you’ve been watching the fucking news. 

Why would obese patients do better? You’ve already said that there might be problems providing care. 

They’ll be a load of reasons. Often it’s just a case of having more in the tank, especially for elderly patients. Muscle atrophy is extremely rapid and very deadly when you are bed bound. And often clinicians will consider obese patients at higher risk, so they might end up with earlier ICU admission for monitoring. It is also likely that obese patients are more likely to be weighed than those in the normal BMI range, especially in stretched healthcare systems, leading to even more bias in the data.

There is one huge factor in Covid deaths that is relevant here, and that is diabetes. For reasons that are not yet fully understood, diabetes, both Type 1 and Type 2, seem to increase the severity of the Covid-19 and raise the risk of death significantly. And although that will be enough for many to point the blame back onto obesity, as there is a significant correlation between obesity and type 2 diabetes, it must be remembered that this is only a correlation. There are a significant number of confounding factors, including several of the most common diabetes medications causing weight gain. There is a complex two way relationship between Type 2 Diabetes and obesity, and yes, for a more complete appraisal, once again, I am going to have to point you towards my book. 

Yeah, your book‘s okay, I guess. For something written by a chef. I actually wish more people would read it before spouting off in the media. Most fuckers don’t appreciate that insulin resistance predisposes people to weight gain, so often it’s a vicious cycle. And whatever all the low carb zealot wankers say, the best way to reduce insulin resistance is through exercise. And fibre. Vegetables, pulses and whole grains, that sort of thing.

Type 2 Diabetes is the big confounder when it comes to the relationship between obesity and Covid-19. Once that confounder is removed, as it was in a recent study looking solely at diabetic patients, something truly surprising is revealed. It appears that the lowest risk group is those with a BMI that is currently considered overweight, people with exactly the sort of bodies that we are constantly told are unhealthy. It is true that people with BMIs greater than 40 do have a significantly higher risk of death, for a number of complex reasons that are compounded in stretched healthcare systems, but so do patients that are underweight. The relationship appears to form a u-shaped curve, with the highest risk for underweight and extremely obese patients, and the lowest risk for people with BMIs in the range now considered overweight, and often referred to as ‘pre-obese’. This means that it if you want to lower your risk of dying, it might actually pay to carry a few extra pounds, especially if you are older. This is not really that surprising given what we know about non-Covid-19 ARDS and ICU admissions. 

That paper was also the only one that actually included an underweight group in its analysis.

But surprise, surprise, I don’t think that is going to be turned into diet advice, and it’s not going to get me and the Captain a rushed through book deal selling the 21 Day Covid-19 Donut Diet Plan. Because actually, the best advice is not to worry too much about your weight at all, try and move around a bit, and eat some vegetables when you can. Most of all, if you want to be healthy, don’t let self serving diet gurus and pseudo-experts make you feel guilty and stressed, because in reality, all they are trying to do is sell you shit advice that you don’t need. Even for people with a BMI over 40, the focus should be on adopting some healthy behaviours, rather than trying everything possible to lose weight. If you are eating a varied diet, not smoking, not drinking to excess, and managing to get some exercise, then you are likely to be healthier and more resilient than many people of lower BMIs.

Another key thing to remember is that all the risks of obesity, even those of association, pail into insignificance compared to many others that newspapers, food moralisers and pointless diet gurus are not talking about. Whilst fat dominates the headlines, age is far more important, as is diabetes, cardiovascular health, ethnicity and socio-economic group. Men are also far more likely to be affected, again for reasons that are not completely clear. 

It is true that men are affected more across the board, but it is a mistake to think that women are safe. Ethnicity does seem quite significant, even after corrections for socio-economic group and co-morbidities, but I suspect that some of the corrections are insufficient.

I do have some other thoughts if you want to hear them.

Yeah, sure, although remember, simple, language. I am just a chef.

Well, this idea about the enzyme that cleaves the spike protein being linked to DHT seems plausible. Insulin resistance would increase it. I would expect women with PCOS to suffer worse outcomes than women without it, because they have elevated free androgens. Basically, they are a model for pre-diabetes. But there's no data on that, even though 10% of women are affected. I'd also be interested in seeing the insulin resistance/SHBG in patients admitted to hospital without a diabetes diagnosis. On a separate note, ACE2 is thought to be protective against heart and lung damage, and it’s higher in women and kids (and DHT is  lower). Obviously, none of this can be proven without clinical trials. Ideally RCTs, but ethically I can't see that happening. I suppose patients could be trialled with anti androgens, but I don't think there is a way to increase soluble ACE2.

Umm, okay. I agree. I think. I suspect these thoughts will be more relevant to some readers than others. Please direct any questions to the Captain.

But whatever the mechanisms, it is almost certainly no coincidence that some of the biggest factors predisposing someone to death from this nasty fucking disease are things to which a great deal of stigma is attached. This is not just a case of poor luck. Obesity, ethnicity, poverty, these are all things that are associated with early death and many types of serious illness. Covid-19 is no exception in this regard. Although the virus knows nothing of your wealth and cares little for your ethnicity or weight, a lifetime of stigma and hardship leaves people more vulnerable to catching this disease, and more likely to die when they do. In the UK, BAME populations are 3-5 times more likely to develop type 2 diabetes in their lifetime, and on average will develop it around 10 years earlier in life. This is not because they are three times fatter, have 5 times less willpower, or eat 3 times more carbs and processed foods. It is because many BAME people live a marginalised existence, are more likely to experience poverty, and are forced to live difficult lives that leave their bodies open to disease progression. Stigma and prejudice are direct causes of disease. The grinding stress of being marginalised and abused in an unfair world makes people sick. The same is true of people in the poorest groups of UK society, and of obese people everywhere. You do not take away that stress and hardship by recommending some simple lifestyle adjustments, or banning processed food. Adding grass fed organic hummus and a recipe for tabbouleh will not relieve that susceptibility. I have said it before and I will say it again. If you want to improve people’s health, you need to improve their lives. If you want a society that is not as susceptible to Covid-19, the best approach is to make it more equal and less unfair.

NEXT TIME – WE LOOK AT THE MANY MORALISERS AND IDIOTS EXPLOITING THE PANDEMIC TO PUSH THEIR OWN AGENDAS, AND CAPTAIN SCIENCE AND I WILL REVEAL MORE DETAILS ABOUT HOW YOU CAN PURCHASE OUR 21-DAY LIFE SAVING ANTI-COVID-19 IMMUNE BOOSTING DIET PLAN PROTOCOLS ONLINE. WE WILL ALSO DISCUSS THE IRONY OF ME SLAGGING OFF PEOPLE SELLING EXPLOITATIVE DIET BOOKS, WHILST SIMULTANEOUSLY PLUGGING MY OWN BOOK, THE TRUTH ABOUT FAT, CURRENTLY AVAILABLE IN PAPERBACK FROM ALL GOOD RETAILERS.

References

Tan Monique, He Feng J, MacGregor Graham A. Obesity and covid-19: the role of the food industryBMJ  2020;  369 :m2237

Williamson, E. (2020) ‘OpenSAFELY: factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients.’ doi: 10.1017/CBO9781107415324.004. 

Zheng, Z. et al. (2020) ‘Risk factors of critical & mortal COVID-19 cases: A systematic literature review and meta-analysis’, Journal of Infection. Elsevier Ltd, (568). doi: 10.1016/j.jinf.2020.04.021.

Simonnet, A. et al. (2020) ‘High prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) requiring invasive mechanical ventilation’, Obesity, pp. 0–1. doi: 10.1002/oby.22831.

Holman, N. et al. (2020) ‘Type 1 and Type 2 diabetes and COVID-19 related mortality in England : a cohort study in people with diabetes’, 

Docherty, A. B. et al. (2020) ‘Features of 16,749 hospitalised UK patients with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol’, medRxiv, p. 2020.04.23.20076042. doi: 10.1101/2020.04.23.20076042.

Nie W, Zhang Y, Jee SH, Jung KJ, Li B, Xiu Q. Obesity survival paradox in pneumonia: a meta-analysis. BMC Med. 2014;12:61. Published 2014 Apr 10. doi:10.1186/1741-7015-12-61

Does Coronavirus Disease 2019 Disprove the Obesity Paradox in Acute Respiratory Distress Syndrome? Jose and Manuel April 2020 https://onlinelibrary.wiley.com/doi/full/10.1002/oby.22835

Goff, L. M. (2019) ‘Ethnicity and Type 2 diabetes in the UK’, Diabetic Medicine, 36(8), pp. 927–938. doi: 10.1111/dme.13895.