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Steve E. Bishop, M.D.

By: Steve E. Bishop, M.D. on September 2nd, 2020

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COVID-19 Update 9/2: That 6% Death Rate Story, Metabolic Health, PCR Test Updates, and More

Lifestyle & Wellness | COVID-19 | Facebook Live Recap

It was another busy week of COVID-19 news. In this week's update, Dr. Steven Bishop talks about that CDC report that some are using to claim only 6% of COVID-19 deaths are from just COVID-19, explains why changing our how we eat is so important, and analyzes the recent report about PCR tests and infectiousness. He also answered questions on approving vaccines before Phase III trials are done, cardiovascular health, and more. 

On That CDC Report About a 6% Death Rate from COVID-19

The CDC updated some of their data that they released in August. And there's a little line in the caption, which basically says 6% of the patients who died of COVID had only COVID-19 listed as their only diagnosis on the death certificate. Some people took this information and ran with it in a way that really is not accurate.

They said only 6% of people were actually dying of COVID and everybody else died of all these other things. And they just happened to have COVID too.

Let me just say categorically: that is false. That is not accurate in any way.

What that data does show is that 94% of the patients who died of COVID had another diagnosis of some kind. It does not say that these other things were what killed them instead of COVID.

What it actually says is more about our population and how unhealthy our population is than, if anything, it says about the virus. So 94% of the people who died had something else wrong with them, and COVID was the precipitating cause of their death, but they had something else wrong, too.

They were overweight. They had diabetes. They had heart disease. They had renal failure. They had whatever else in the background. And then COVID was what got them. 

Now, there are certainly some people included in those numbers who likely may have passed away from any number of things that might have tipped them over health wise. That is true. People who had advanced cancers, people who had advanced immune system problems, other things they could have just as easily died of any virus that they contracted, whether it was COVID or whatever. That being said, that is in proportion, a small number of people.

So what this data shows again, is not that the virus is less dangerous than we thought or anything else. It doesn't tell us anything new about the virus. This data just reconfirms what we have known since the pretty much since the beginning, which is that if you have underlying medical conditions, and in particular metabolic problems, you are at much higher risk for dying from this virus.

And that's really what I want to talk about more today, this whole issue of metabolic health. So about 88% of people in the United States are metabolically unwell. What does that mean? So that means that they either have diabetes. They have pre-diabetes. They have high triglycerides in their blood. They have hypertension. They have excess weight. Any of these things, they fall in the category of abnormal metabolic syndromes.

Prediabetes — hyperinsulinemia is another way to describe this — 88% of American adults fall into this category. It is a crisis, and it's really something that we need to address and address promptly for many reasons, not just because of COVID. There are going to be more pandemics in the future. These are issues going on every day. People are dying of these metabolic syndromes, dying of heart disease, dying diabetes, dying of cancer that's related to obesity.

We've got to address these problems, and these problems are addressed not with a COVID vaccine, which we need, and not with a COVID treatment, which we need, but these problems are addressed by making the population healthier. And so how do we do that?

We've got to change the food we are eating. This is the most important thing that we can do as a nation, to not only deal with COVID, but deal with all of our health issues.

We've got to change the food we're eating. We have got to stop eating processed foods. We have got to stop eating foods that comes in packages and boxes. We have got to stop eating things that are high in sugar and high in carbohydrates that are bad for us and that drive these metabolic disorders.

This is one of my primary roles at PartnerMD. As the director of wellness, we run a healthy metabolism program where we teach people these issues. There are a lot of physicians out there who focus on this as well, beyond what we do here at PartnerMD. But please connect with your doctor. Talk to them about transitioning to a low carbohydrate diet, or at least a diet where you are avoiding processed foods and excess added sugars.

Top 3 Ways to Start Changing How You Eat

So my top three pieces of advice to really start to make a change:

1) Don't drink your calories.

If you're drinking something that contains, whether it's sugar or whatever, it doesn't matter. If you're drinking a calorie, stop doing that. It's bad for you.

2) Read nutrition labels. Check out what you're eating.

Start looking at the back of the packages of the things you have in your pantry and in your fridge and everywhere else. Check out the total carbohydrates. Check out the total calories. Check out the ingredients. See what you're putting in your body. This is extremely important. 

3) Move.

You've got to get out of the house. And I know this is tough when people are in lockdown still in many areas. This is difficult. You've got to get out. You've got to move every day. You've got to get some sunlight. These things are critical for your immune system. They are critical for your vitamin D levels, which is important for running your immune system.

Exercise in general is good for you and your immune system and your weight and everything else and your metabolic health overall.

But we've got to start changing our food. Start with these three things. Don't drink your calories, check the nutrition labels, and start getting aware of what you're eating. Get outside 20 minutes a day, walk a little bit, get some sunlight. Those are my top three things.

There's a whole lot more to do to do, but those are the places to really start figuring out what's going on and addressing this problem of metabolic disease in the United States. This is what we've all got to do. It's a decision that we have to make individually to change the way we eat. And you've got to do that.

And that's other than washing your hands, wearing your masks, staying away from sick people, isolating, other than those things that are specifically related to the virus.

This is the single most important thing you can do for your health. Both for COVID and for the long-term. Get control of what you're eating and what your family's eating on a daily basis, improve your health that way.

Positive PCR Tests? 

The next thing I want to talk about is this other news article that came out, which is related to PCR testing. Some folks dug into the data pretty deeply and what they have found is that there's a lot of people who have a positive PCR test, and as we know, many people are asymptomatic with positive tests and that's a good thing, but what we are seeing as well is that many of these people with positive tests may, in fact, not be infectious.

This is good news in one way, because it means that people are not spreading the virus nearly as much as we thought. However, I think it is something that can give people false confidence. So we don't want people getting their PCR and because they feel well, saying, "well, I saw this thing and this article, so I'm probably not infectious. Even though my PCR is positive because I feel okay. And so I'm going to go out and do whatever I want."

I don't think that we're at a point yet where we can say you can disregard your PCR. What I do think is that this information is important for people who are making public policy, people who are making decisions about schools, people are making decisions about lockdowns and other things, and who continue to want to follow raw case numbers as the primary metric for making these decisions.

I think it proves once again, as we have been saying for months, that following raw cases is probably not the most accurate or best way to manage this issue. Following hospitalizations, deaths, other things like that is probably more accurate and better data because it's more clear cut data, because there's just so much we don't understand about the asymptomatic piece and all of this other stuff.

And what this really is related to is the way that the PCR tests are performed. So a PCR test, let's go back a little bit to the science on this. PCR is polymerase chain reaction. So what is that? That's a lot of fancy words for what these tests do is take a whole lot of complex molecular processes and what it boils down to is that the tests replicate DNA or RNA that exists in the sample.

If you put in a swab into the machine and someone has COVID, that machine is going to start trying to replicate that COVID RNA until it reaches a level that's detectable by the machine's sensors.

So essentially what that means is the machine runs through something called a certain number of "cycles" in order to do this. So the machines that have been running, they've been running 35, 36, 37 cycles. The more cycles it takes to detect the DNA or the RNA in the sample that the less virus is present, because it's harder for the machine to find it in the sample.

What they have found is, most of the machines out there running in the mid-30 cycles and what this data showed from this article and others, is that most people, if it takes more than 24 cycles or so to detect the virus in the sample, you're likely not infectious. It doesn't mean definitely not infectious. It means likely non-infectious. So let's just keep it a little bit balanced on that perspective piece.

I think that in one way, this is good news, but also we don't want to give people false confidence. So I suspect what will happen is the machine manufacturer will start adjusting the cycle numbers down. We wanted the cycle numbers to be high and us to be very sensitive in detecting the virus, especially in the beginning, because now that we're six months into this, we have the perspective of hindsight. And we know in general what the mortality rate is. We know more about how the virus works. We know who's at risk. All of these things

But you have to think back to March, right? We did not know what this was going to do. We did not know if the mortality rate was going to be 1% or 10% or 30%. We had no clue. And so we wanted the tests for this virus to be extremely sensitive, to find it in every case, because we needed to very closely monitor who had it, who didn't, and really track these things down.

This may not be as necessary at this point, just like we don't detect every single case of flu virus that goes on every year or every single case of a cold virus. We may not, because the mortality rate is much lower than we feared, need to detect every single possible case of COVID as it comes up, because a lot of these people are asymptomatic and they may not be spreading it.

But we did not know that in the beginning. So I don't think it's fair to go back now and say, well, see all these cases you counted, these are not legitimate. I don't think that's a fair representation. I think that people who were doing the testing, who were doing these things, they were doing what seemed best at the time. Now that we have this new information, it's important that we make changes going forward.

And probably the companies need to reduce the cycle count on the PCR machines so that we are not detecting all these probably asymptomatic and noninfectious people, because it's not that important to know. So that's kind of my take on this data. It's good data. It's not something that I would hang my hat on. If I get a positive PCR and say, well, I'm not infectious. Don't take that interpretation of the data yet.

Let people review the information. Let the scientists take a thorough look at this information. Let the machine manufacturers make the adjustments to the PCR machines and let this play out over time. I don't think it's something where we can simply say, okay, we can disregard all these PCR tests. We're not there yet, but I think it is good information. I think it's, we're moving in the right direction with these things.

Your Questions, Answered.

  • I’ve seen an article going around social media about the possible role of bradykinins in Covid. What are they, and what should we know about them in relation to Covid-19?

    Bradykinins are a molecule that's involved in a whole lot of processes, including inflammatory reactions and other things in the body, blood pressure control and all, that whole cascade. They do many things. Now what's interesting, so the article discusses a theory about whether high bradykinin kind of levels are contributory to the inflammation and the cytokine storm that seems to occur with the virus in some people. I think it's interesting. I think it's another one of those interesting theories that needs further evaluation. I'm a little suspicious of the theory, because all the data that has come out in the last few months showing that people who were on these ACE inhibitor drugs. So ACE inhibitors like lisinopril, fosinopril, and those sorts of things that are very common blood pressure drugs at first, people were anxious about these drugs because they thought people might be sicker, and partly it was probably related to this bradykinin issue and the ACE two receptor issue.

    Now, the reason that this makes me a little suspicious as what we found in the intervening months is that people on ACE inhibitors, they actually tend to do better with the virus than people not on them in terms of, other things being equal, people who were on these blood pressure medicines are not at increased risk for doing poorly with the virus and may do better actually than some other people. So why does this make me suspicious of the bradykinin theory? So ACE inhibitors, what they do is they increase bradykinin as an indirect side effect of the way that the drug works at the molecular level. Bradykinin levels tend to go up very, very high on these drugs.

    And so if the high bradykinin levels were associated with worse outcomes, you would expect that people on ACE inhibitors would do worse than people not on ACE inhibitors, which doesn't seem to be the case in the data we've had so far. This is the etiology of a common side effect of ACE inhibitors, a cough, anybody who's been on one of these drugs before and has developed a cough. This is because of bradykinin. The bradykinin levels drive that cough reflex for one reason or another. And so, the bradykinin levels do go pretty high on these ACE inhibitors. So again, I can't quite jive with the theory about the bradykinin and with the ACE inhibitor piece, because the data doesn't seem to indicate that people in ACE inhibitors do worse with the virus than others, despite their bradykinin levels likely being quite a bit higher than normal people.

  • What do we know about the possible cardiovascular effects of Covid-19? Are these a concern only for the most serious cases? I’ve seen some reporting that harm can occur in less severe cases.

    Yes. This is an ongoing area of investigation as well. So the virus does seem to have an affinity for vascular tissue, heart included. Vascular tissue, the heart, other things, they have these ACE receptors, which is what the virus docks and latches onto in order to start the infection cycle. So it doesn't surprise me that people are having cardiovascular problems related to the virus, even in the asymptomatic people.

    There are many viruses that cause problems with the vascular system. COVID is not the only one. We come across cases as physicians from time to time where people get viruses that for many people are completely harmless, but for some people, especially younger people can cause acute heart failure, because of the damage done to the myocardial tissue by the virus or the indirect actions of the virus.

    Coxsackie virus is another common childhood illness that gets passed around frequently in some people, both children and young adults. It can cause an inflammatory myocarditis and can cause heart failure. There are other viruses that do this as well. Influenza can do this too. And so there's that piece. There's sort of the direct action of the virus on the cardiovascular system.

    And then there's this other second piece of the puzzle that we need to tease out a bit, which is that, if people are getting very sick with COVID or anything else, any type of sepsis or severe illness can put a significant strain on the heart. And that can cause damage to the heart muscle, can cause heart attacks, which are not like your standard classic heart attack, but they're a heart attack caused by strain on the heart muscle.

    This can be caused by severe sepsis of any kind:  pneumonia, urinary tract infection, COVID, whatever it might be. Any kind of severe illness can cause these kinds of what's called demand dischemia injury to the heart, because of the stress placed on the heart muscle and the need for more oxygen and other delivery during the illness.

    So I think there's two things going on there. There's the direct action of the virus on the vascular tissue.

    And then there's the people who get very sick with the virus and have these sort of stress response reactions within the heart. It's not surprising to me that folks are having cardiovascular problems. I think it's unfortunate. The scale of it seems to be a little higher than we would want to see that's for sure, but I'm definitely not overly overly surprised by that information.
  • I’ve seen media reports that the FDA is considering approving an emergency use authorization for a vaccine even before Phase 3 data has been collected and analyzed. What are your thoughts about their considering doing this?

    My short answer is: I think it's a terrible idea. It's the same thing I was saying last week with Dr. Oliver, our health commissioner, making, I think, premature comments about requiring a COVID vaccine for every citizen in the Commonwealth of Virginia before we have any data back on any of the vaccines in trial.

    I think my comments are similar for this. I don't think we should overly rush this. I think we should be efficient and move with all speed that we can, but I don't think we should sacrifice safety. And I don't think we should sacrifice the accurate evaluation of the data that's coming out about the vaccine in order to have a vaccine out there. I don't think that that is a good idea.

    I hope before anything like that gets approved, and certainly I hope that before any further discussion of mandating the vaccine for anyone continues, I think that we all need to have a chance to see the data, see what's going on with that and all be informed about the risks and the potential benefits of any such vaccine before we start really pushing this on the lay public at large. I think doing so in a manner, in some of these too quick manners is a dangerous precedent that we should not follow. 

  • How do you feel about our sharing the holiday of Sukkot with our kids and grandkids in a sukkah that holds 25 people and we are a total of only 11 people...Does this sound safe enough or still too risky?

    No, I think that's exceptionally safe. I think you're doing everything you can to minimize the risk while still being able to celebrate Sukkot in a, in a safe and healthy manner. I think what you're doing is great.  I wouldn't add anything to that necessarily. I would continue on with the plan that you have and as long as everybody's relatively comfortable, I think that'll be a successful thing. 

  • I walk between 1 hour to 1.5 seven days a week. Is this enough?

    Yeah, absolutely! Do it in the sunshine. Make sure you're getting a few minutes of sunlight every day. 20 minutes is usually enough for most people in order to make all the vitamin D you need. So definitely good job on that. And get your 20 minutes of sunlight every day and that would be good. So you're doing great with that.

  • What’s your feeling on going for hair cuts, dentist appts, flying commercial, etc? 

    I think as long as your stylist and your dentist are doing the recommended things that this is fine for most people. I would encourage you to wear your mask, like everyone is discussing, wear your mask. Ideally they should wear a mask or at least a face shield as well to minimize the risk of transmission. But I overall I think this is, this is fine.

    Flying commercially is a little bit more difficult question. I think it depends a little bit on the airline. We're going to fly commercially this weekend, my family, and I, we have to go to a wedding out of state. We're going to fly to Cleveland for that, and we are probably going to wear N95 masks on the plane. And I think that for especially those who are higher risk or who are older, if you're going to fly commercially, I would wear an N95 rather than any other type of mask, because an N95 is going to give you a better protection from the virus getting to you as opposed to a lot of these cloth masks and other things that are really more about you reducing transmission to other people. That N95 is more about protecting you, the wearer. So if you're going to fly commercial, I think it's fine to do. I think I would try to choose an airline that's leaving that middle seat open to give a little bit more space, and that maybe isn't filling up the plane so much.

    So I would do that and I would consider wearing an N95, if you can get your hands on them while you're flying commercial, but otherwise, if you're an average- or low-risk person, I think it is fine. If you're a high-risk person, I would consider avoiding air travel. If you can't avoid air travel, then consider strongly wearing an N95 mask on the plane while you're in flight.

  • For exercise, what balance of strength and cardio training do you recommend? Or is simply moving enough no matter the details.

    In terms of general metabolic health and everything, for the cardio piece, walking for 80% of people is sufficient.  Walking 20 minutes a day enough that you get your heart rate up a little bit and are slightly out of breath is usually enough for most people.

    In terms of metabolic health, building muscle, improving bone density, improving your metabolic rate, and improving your insulin sensitivity and blood sugar, weight training is by far and away the more important of the two. I would prioritize weight training over cardio. For most people I would do the weight training.

    I would start with the walking piece if you're someone who's very sedentary or who doesn't do a lot of movement, just start moving with the walking. That's the first thing to start with. You're going to get a lot of bang for your buck out of that.

    If you're already someone who's fine in that realm and you can walk 20-30 minutes, walk half a mile or a mile without too much difficulty, then I would say time to add in the weight training to improve the metabolic health even further. And I would prioritize the weight training over any more intense cardio than just walking.

    Especially the older you are, the more you need to prioritize the weight training. Muscle loss and bone mass loss, as you get older, are two critical factors in terms of overall health and metabolic health in particular. So definitely prioritize those things.

  • Please comment on college shutdowns.

    I think that's a complicated thing. I think it probably depends on each college has sort of their own situation going on. I think it does get back to this issue of the PCRs, right? A lot of these younger folks in the colleges, they are healthy. They are not at risk for, very low risk, for having bad outcomes from the virus and these sorts of things.

    With this new information coming out about a large number of people with positive PCR tests perhaps and probably not being infectious, I think we probably need to rethink how we're screening the college kids, especially if they are not symptomatic with the virus at this point.

    We talked about this a little bit last week and the week before. There are two different sides of this equation. So there's the students and then there's the teachers, right?

    The students are pretty low risk, mostly being 18 to 22 and mostly very healthy. So I think for them, we really probably may not need to be screening them for asymptomatic infection, especially if they're not going to have a lot of very close contact with their professors and older folks in an enclosed setting, cause many classes, even at universities that have allowed people to come back to the dorms, many classes are still online or partly online.

    I think if people are being reasonable about their exposure and close contact with the older professors and teachers and staff, then I think that it's not super important that we figure out all the asymptomatic cases among the college students. Now, if they're sick, right, that's different. If they're sick, then we definitely need to test them. We definitely need to isolate them and do those sorts of things.

    But I think I'm leaning toward, perhaps we need to not be aggressively screening asymptomatic college kids at this point, because of the information that is coming out around the PCR testing and that we're maybe picking up too many tests that are amongst people that are actually not at risk of transmitting it to others. So that's kinda my comment on that.

    I think that, again, I think that the manufacturers will adjust the cycle settings and the test reporting information on these machines in the coming weeks and months, so we will balance out this issue of the detecting patients who are not really at risk of transmitting the virus to others.