Coconut- Macadamia Crust with Lime Curd, Sliced Mangoes and a Guava Glaze
Serving Size : 10
2 1/2 cups roasted macadamia nuts (about 10 ounces)
1 7/8 cups sweetened shredded coconut
1 5/8 cups almonds- sliced
5/8 cup golden brown sugar — (packed)
3 3/4 large egg whites
1 1/4 cups sugar
½ cup fresh lime juice
12 1/2 large egg yolks
5/8 cup chilled unsalted butter — (1 stick) cut into pieces
Make crust: Preheat oven to 350°F. Butter eight 4-inch-diameter tartlet pans with removable bottoms with butter, preferably ghee. Combine nuts, coconut and brown sugar in processor. Process until nuts are finely chopped. Transfer to large bowl. Beat egg whites in another large bowl until soft peaks form. Fold whites into nut mixture in 3 additions (mixture will be thick and sticky). Let mixture stand 10 minutes.
Using plastic wrap as aid, press about 1/3 cup nut mixture onto bottoms and up sides of each prepared pan. You can use individual tart pans, a large tart pan or a non-stick large muffin pan to make individual tart crusts. Place pans on baking sheet. Bake until crusts are puffed and begin to brown, about 20 minutes. Cool crusts in pans 5 minutes. Using oven mitt, gently remove pan sides; cool crusts completely on rack.
Make lime curd: Whisk sugar, lime juice and yolks in large metal bowl to blend. Set bowl over saucepan of simmering water; whisk constantly until mixture thickens and candy thermometer registers 180°F., about 9 minutes. Gradually add chilled butter, whisking until melted and well blended. Press plastic wrap directly on surface of curd. Refrigerate until cold, about 3 hours.
Fill each crust with 5 tablespoons lime curd. Arrange mango slices decoratively atop tartlets. Whisk guava jelly in heavy small saucepan over low heat until melted. Brush over mango slices.
3 tablespoons distilled white vinegar
3 tablespoons sugar or honey
6 tablespoons Dijon mustard
6 tablespoons mayonnaise
4 large pickling cucumbers, peeled, cut into 1/2-inch cubes (about 2 cups)
2 large mango, peeled, pitted, cut into 1/2-inch cubes (about 1 1/2 cups)
1 pound cooked medium shrimp
3 tablespoons chopped fresh dill
Hot pepper sauce
Mix vinegar and sugar in small bowl until sugar dissolves. Whisk in mustard and mayonnaise. Cover and chill.
Combine cucumbers, mango, shrimp, and dill in large bowl. Pour dressing over; toss to coat. Season with salt and hot pepper sauce.
June 7, 2020 — 11:20 AM
The concept of microdosing is all the rage these days—and for a good reason. Microdosing refers to the practice of taking tiny portions of a substance, usually around one-tenth or one-twentieth of a normal dose. The idea is to reap the positive benefits of a substance, without any of the negative.
What’s more, everyone’s body is different, so people respond to substances in their own unique way. Plus, sometimes it’s easier to ramp up something slowly rather than go straight for the higher dose, which is why I often recommend microdosing to my patients in various contexts. Recently, one practice I’ve been fascinated with is microdosing caffeine.
What is caffeine microdosing?
To achieve an optimal energy zone, you generally need to consume between 60 mg and 100 mg of caffeine. Plus, your overall ability to concentrate and perform is more ideal when you can remain in this sweet spot over a steady period of time. To put that into perspective, one cup of coffee generally contains about 100 mg of caffeine, a shot of espresso is 85 mg of caffeine, and a cup of green tea is 40 mg of caffeine.
One way to optimize your intake is through microdosing, or consuming small amounts of caffeine throughout the day. This might look like drinking a cup of coffee in the morning, and then only having green tea throughout the rest of the day. Or slowly sipping your coffee in the morning, which may help you drink around 10 mg or so of caffeine at a time. These techniques may give you enough stimulation to help you be as productive as possible without feeling jittery or anxious.
The benefits of caffeine, even in small doses.
While too much caffeine can cause negative side effects like anxiousness or a rapid heartbeat, there is a lot of evidence in scientific literature regarding caffeine, its health benefits, and its potential as a microdosing agent.
In addition to increasing energy and improving cognition, there is also some research that indicates it may affect inflammatory conditions and autoimmunity. Other literature suggests that natural caffeine sources like coffee may help prevent prediabetes and type 2 diabetes.
Caffeine has also been researched since the 1970s as a performance-enhancing substance, for athletes and military, but often at moderate to high doses. However, what we are finding now is that low doses can be safer and better for the body: They can help improves alertness, mood, and cognition during and after physical exercise but with few (if any) side effects. In fact, a recent review suggested that low doses of caffeine, as low as 3 mg, can be just as effective as higher doses.
What’s more, scientists at Harvard did a randomized, double-blind placebo-controlled study where 16 male subjects microdosed caffeine for, and were sequestered for, 29 days. They were also deprived of time cues so they could simulate the extended wakefulness that doctors, military, and emergency services first responders often experience. What the researchers found was that those who took the low-dose caffeine supplement performed better on cognitive tests and had fewer accidental sleep onsets. The results suggest that microdosing caffeine can be especially helpful in circumstances in which an individual must wait for the opportunity for a good night of restorative sleep (think essential workers).
Should you try microdosing caffeine?
When patients are interested in optimizing their nutrient and vitamin levels, I often run a nutritional genomics panel. When I do this, one of the common genes that is tested for is a gene that affects caffeine metabolism. If a patient has a gene mutation in the CYP1A2 gene, they have an increased risk of high blood pressure or heart attack if they drink more than 200 mg of caffeine daily.
This is all to say that some people are more sensitive to caffeine than others. Maybe you’ve already noticed this about yourself anecdotally—perhaps after having two cups of coffee you feel shaky or anxious. For context, most people tend to get into the jitter zone when they hit 140 mg to 200 mg, which is often the case when drinking energy and power drinks.
Regardless of how you metabolize caffeine, taking it in small amounts can help you hone in on the exact dose you need to optimize your focus, creativity, mood, and energy without worrying about what happens when you “crash” from the caffeine high and start getting headaches and other side effects.
Cautions for caffeine microdosing.
One thing I always like to caution people about is reading labels. You want to make sure that your good intentions are not negated by taking a product that has other unhealthy ingredients mixed in or contains caffeine from an unnatural source.
I always advise my patients to look for labels such as “from a plant source” like green coffee beans or green tea leaves, for example. If this isn’t disclosed on the label, it’s possible that the product you are taking could be synthetic and made in a lab. Also there are more health benefits from using a natural source of caffeine rather than a synthetic processed form. Like with anything you ingest, make sure the products are true to their purpose.
Also, please remember that it is important to consult with your doctor before trying something new, like caffeine microdosing.
Microdosing can be a useful way to reap the benefits of caffeine. Especially if you are a slow caffeine metabolizer like me, it can help you avoid unwanted side effects from excess coffee. Just be sure to speak to your doctor before making any drastic changes to your nutrition routine.
Ready to learn how to fight inflammation and address autoimmune disease through the power of food? Join our 5-Day Inflammation Video Summit with mindbodygreen’s top doctors.
Marvin Singh, M.D is an Integrative Gastroenterologist in San Diego, California, and a Member of the Board and Diplomate of the American Board of Integrative Medicine. He is also…
Hypertension: Celery contains potassium, which counters the harmful effects of sodium
“Celery stalk salt content is low, and you also get fibre, magnesium and potassium to help regulate your blood pressure, as well,” notes Cleveland Clinic.
Foods that are rich in potassium are particularly important in managing high blood pressure because potassium lessens the effects of sodium, according to the American Heart Association (AHA).
Sodium, which is found in salt, raises your blood pressure, but the more potassium you eat, the more sodium you lose through urine.
“Potassium also helps to ease tension in your blood vessel walls, which helps further lower blood pressure,” explains the AHA.
HIGH blood pressure doesn’t produce symptoms so the only way to keep it in check is to make healthy lifestyle decisions. Eating a healthy diet is a surefire way to reverse high blood pressure and no diet would be complete without this green snack.
High blood pressure is when your blood pressure, the force of blood flowing through your blood vessels, is consistently too high. Over time, this causes your blood vessels to lose their elasticity, restricting the amount of blood that flows through them. Restricting the supply of blood to your heart is particularly concerning because it can trigger a heart attack.
Unfortunately, high blood pressure does not usually have any symptoms, so the only way to find out if you have it is to get your blood pressure checked.
According to the NHS, blood pressure tests can also be carried out at home using your own blood pressure monitor.
Blood pressure is measured in millimetres of mercury (mmHg) and is given as two figures.
Systolic pressure – the pressure when your heart pushes blood out – is the top number and diastolic pressure – the pressure when your heart rests between beats – is the bottom number.
“High blood pressure is considered to be 140/90mmHg or higher (or an average of 135/85mmHg at home) – or 150/90mmHg or higher (or an average of 145/85mmHg at home) if you’re over the age of 80,” explains the health body.
If the test determines that your blood pressure is too high, you must make healthy lifestyle decisions to lower it.
Overhauling your diet plays a key role and a robust body of evidence can point you to the most heart-healthy items.
According to research, snacking on celery can help to combat high blood pressure.
your physician before using this exercise equipment or beginning any exercise program.” It’s a well-intended message designed to be responsible and keep people safe.
But scientists called for public warnings with exactly the opposite message at a satellite symposium that was organized by the American Society for Nutrition on Friday, April 25. The event, sponsored by Herbalife Nutrition Institute, took place at Experimental Biology in San Diego.
Endocrinologist Dr. David Heber, director of the UCLA Center for Human Nutrition, reminded that a sedentary lifestyle has disastrous pathologic consequences. He said that, combined with obesity, physical inactivity leads to abdominal adiposity, visceral fat, chronic systemic inflammation, insulin resistance, and ultimately diabetes and cardiovascular disease.
Underlining the consequence of protein breakdown due to physical inactivity, Dr. Heber counseled that the muscle loss and a subsequent drop in resting metabolic rate puts the U.S. population at risk of widespread sarcopenic obesity. Muscle burns 30 Kcals per kilogram versus fat’s only 6 Kcals per kilogram, he reminds.
Former U.S. surgeon general Dr. Richard Carmona said that the problems of getting people to do more for their health wasn’t a matter of needing more knowledge or authority. “It’s getting people to listen,” he said. “Where we have failed is really in the translation. We need better translators of science.”
Sharing some of his 2002-2006 term experiences, Dr. Carmona illustrated how obesity was burdensome to the country by ways of high costs — and even to national security. After Hurricane Katrina, for example, he said a lot of the people affected had low health literacy, were obese, and had several medical conditions related to obesity such as high blood pressure and type 2 diabetes. These issues exacerbated the tragic event.
“Obesity doesn’t get the attention it deserves,” he said. “Health care is really sick care and it’s driven by obesity.”
University of Colorado Professor of Pediatrics and Medicine James Hill, Ph.D., said regular physical activity of an hour or more daily was one of the behaviors that has shown to be key in leading to long-term weight management success, according to the National Weight Control Registry of which he co-founded. The registry follows more than 6,000 formerly obese people who have lost weight and kept it off permanently.
But the reason physical activity is important had little to do with burned calories, he explained. “In my opinion,” he said, “the important point is that it helps our bodies operate in the way they’re meant to operate.”
Hill said once physical activity reaches a specific threshold it has a way of adjusting the body’s appetite according to energy expenditure. Showing a figure modified from the work of Jean Mayer and colleagues, he illustrated the concept of the physical activity threshold explaining that to the left of the bar was an unregulated zone and to the right there was a regulated zone.
“Our biology works best at high level of physical activity. Energy expenditure is driving the bus,” he said. “But most of us are left of the bar.”
Most now includes 88.9 percent of the world population in 122 countries, according to professor of epidemiology and kinesiology Bill Kohl, Ph.D., of University of Texas at Austin’s Department of Kinesiology and Health Education.
In July 2012, Kohl reported conclusions in The Lancet that one out of three (31.1 percent) adults didn’t meet physical activity guidelines of 150 minutes per week, that men were more active than women, that inactivity increases with age, that inactivity is higher in high-income countries. In addition, he found that four out of five (80.3 percent) adolescents didn’t meet guidelines of 60 minutes per day and that boys were more active than girls.
Throughout the world, Kohl said, overall physical activity is declining rapidly. He cited research of Timothy Church and colleagues, as well as a review paper by Shu Wen Ng and Barry Popkin, showing that one of the major reasons had to do with drastically declining from occupational physical activity.
“I submit to you that this isn’t just a weight loss problem,” he said. “It’s a pandemic. If the number of people in the world that were physically inactive were smoking, we’d be up in arms. We should be up in arms.”
How much physical activity should one do to gain an impact? There’s a dose-response effect, according to John Jakicic, Ph.D., professor and chair of the University of Pittsburgh department of health and physical activity.
Based on his prior research and from Goodpaster et al and Slentz et al (and unpublished data he shared), he said that the higher level of physical activity one has, the greater the body weight change, the greater impact on visceral adiposity, and greater reduction of HbA1c (glycated hemoglobin).
Rather than put up warnings about exercise, he said, why not put up a new cautionary statement: “Physical inactivity has been shown to be associated with increased mortality, morbidity, and lower quality of life. Please consult with your physician if you decide not to engage in regular periods of daily physical activity.”
Dr. Julian Alvarez Garcia of University of Alicante (Spain), reminded that exercise is a “very complex phenomenon.” Athletes, for example, will often time nutrition before, during, or after exercise to fuel specific adaptations such as for weight loss, endurance, or strength.
Moving what he called “a step beyond energetics,” Dr. Garcia suggests that a different mindset be used when eating. We shouldn’t think of nutrition as feeding exercise, but “feeding adaptation,” he said.
Avoid dairy and gluten containing foods, exercise and stop smoking..
First it’s important to understand how the virus attacks our lungs. When people are infected, the virus travels to the mucus membranes and then the lungs. To control the infection, the body responds with inflammation in the lungs. And this inflammation prevents the lungs from being able to oxygenate the blood and remove carbon dioxide, which leads the patient to gasp for air and suffer more serious illness.
But there are things you can do to improve respiratory health, just by changing a few lifestyle factors, according to Dr. Robert Eitches, an allergist and immunologist at Cedars-Sinai Medical Center in Los Angeles. Enhancing your respiratory health doesn’t prevent you from getting infected, he said. But it does have benefits that may reduce the severity of the illness if you are infected, and therefore your exposure to the virus.
Here’s how you can strengthen your body’s respiratory capacity so that if you do get infected with coronavirus, the chances of serious illness may be lower.
Reduce excess mucus buildup
“Mucus is naturally occurring in our bodies, and it provides a very important function to maintain good health in our respiratory tract,” Steele said. “It helps to capture [allergens, bacteria and viruses].”
In our respiratory tract, we have little hairs called cilia that move those threats out of our tract. We swallow the majority of mucus, Steele said, but when we have things that irritate our nasal passages, we can produce too much mucus and be unable to clear it. This creates a breeding ground for bacteria and viruses, and blocks oxygen from entering and leaving the pathways of the lungs.
We also have mucus in our lungs. People with asthma produce too much mucus, which can predispose them to blockages and inflammation in their airways, Steele said.
There may be a connection between diet and mucus buildup. “Some people believe that inflammatory foods such as milk and wheat increase mucus production,” Eitches said. “Another school of thought that I have seen to work both anecdotally with my patients and with myself is eating spicy foods.”
Spicy foods that have capsaicin — chiles, jalapenos, cayenne, hot sauce — can thin mucus and allow it to be coughed out.
Exercise can improve respiratory capacity, or breathing ability. Alveoli are tiny, balloon-shaped air sacs arranged in clusters throughout the lungs. They’re integral to the respiratory system, as they exchange oxygen and carbon dioxide to and from the bloodstream.
When a person is sedentary, Steele said, that results in a phenomenon called “atelectasis,” when the lung sacs don’t have enough air and collapse slightly. To improve the lung sac capacity, people have to “breathe against resistance,” he added.
“You can think of it like a partially deflated balloon,” he suggested. “And what’s the way that you keep the air inside a balloon? You tie a knot in it to increase the resistance, so the air has to work harder to get out.”
By breathing against resistance when exercising, you’re “actually helping to expand and keep open the air sacs” in your lungs, Steele said.
In addition to cardio, yoga and stretching, breathing exercises such as pursed lip breathing and deep yogic nasal breathing can help and are easy to do wherever you are, Eitches suggested. Pursed lip breathing is when you take in a deep breath with your mouth, close your lips, then exhale through them as if you’re blowing up a balloon. There are similar benefits from deep yogic nasal breathing as you filter the air through your nose.
Improving your lung function means “you would be less likely to hit a critically low lung function state, which would in turn cause you to not be able to oxygenate your blood,” Eitches said.
“Respirators essentially breathe for you to try to push open your airways. These exercises will teach you how to fight off the respiratory side effects [of Covid-19] on your own.”
Additionally, Steele said, exercise decreases inflammation in the body and can reduce the occurrence of acute respiratory distress syndrome, a serious complication in some patients hospitalized with Covid-19.
One of the most important steps to improving your respiratory health is avoiding anything that impairs lung function, such as smoking cigarettes and vaping, Eitches said.
Smoking and vaping cause irritation in the lung airways that leads to permanent, adverse effects on lung function by destroying lung tissue where air exchange occurs.
“Smoke is composed of small particles; when inhaled, the particles get stuck in the lungs,” Eitches said. “This begins a vicious cycle of permanent lung damage.”
Both activities can also suppress the immune system, which you need to be able to help fight infections.
Dr. Ryan Steele, an allergist-immunologist and assistant professor at the Yale School of Medicine, cautioned against smoking marijuana, too.
Many candles have metal wicks, which are vaporized along with smoke and can cause similar lung damage.
Taking steps to improve respiratory health is another tool to add to one’s prevention kit, as we weather the pandemic and anticipate another possible wave in the fall.
“The stronger your baseline health, the stronger your body will be to fight off infections,” Eitches said. “It’s like having the appropriate ammunition to fight a war.”
CNN’s Brian Fung and Jen Christensen contributed to this report.
COVID-19 is proving to be a disease of the immune system. This could, in theory, be controlled.
Note from Millie– I posted yesterday about working to improve your immune system. Never have we been more acutely aware of how important this is. Americans are, for the most part, unhealthy. Eventually each of this will have this virus. How strongly it effects each of us is based on what shape our immune system is. If you are even 10 pounds overweight, you are malnourished. I urge you to take this time to make those changes which will help you repair your gut, where all disease begins.
This article reinforces what I am saying…
The COVID-19 crash comes suddenly. In early March, the 37-year-old writer F. T. Kola began to feel mildly ill, with a fever and body aches. To be safe, she isolated herself at home in San Francisco. Life continued apace for a week, until one day she tried to load her dishwasher and felt strangely exhausted.
Her doctor recommended that she go to Stanford University’s drive-through coronavirus testing site. “I remember waiting in my car, and the doctors in their intense [protective equipment] coming towards me like a scene out of Contagion,” she told me when we spoke for The Atlantic’s podcast Social Distance. “I felt like I was a biohazard—and I was.” The doctors stuck a long swab into the back of her nose and sent her home to await results.
Lying in bed that night, she began to shake, overtaken by the most intense chills of her life. “My teeth were chattering so hard that I was really afraid they would break,” she said. Then she started to hallucinate. “I thought I was holding a very big spoon for some reason, and I kept thinking, Where am I going to put my spoon down?”
An ambulance raced her to the hospital, where she spent three days in the ICU, before being moved to a newly created coronavirus-only ward. Sometimes she barely felt sick at all, and other times she felt on the verge of death. But after two weeks in the hospital, she walked out. Now, as the death toll from the coronavirus has climbed to more than 150,000 people globally, Kola has flashes of guilt and disbelief: “Why did my lungs make it through this? Why did I go home? Why am I okay now?”
COVID-19 is, in many ways, proving to be a disease of uncertainty. According to a new study from Italy, some 43 percent of people with the virus have no symptoms. Among those who do develop symptoms, it is common to feel sick in uncomfortable but familiar ways—congestion, fever, aches, and general malaise. Many people start to feel a little bit better. Then, for many, comes a dramatic tipping point. “Some people really fall off the cliff, and we don’t have good predictors of who it’s going to happen to,” Stephen Thomas, the chair of infectious diseases at Upstate University Hospital, told me. Those people will become short of breath, their heart racing and mind detached from reality. They experience organ failure and spend weeks in the ICU, if they survive at all.
Meanwhile, many others simply keep feeling better and eventually totally recover. Kola’s friend Karan Mahajan, an author based in Providence, Rhode Island, contracted the virus at almost the same time she did. In stark contrast to Kola, he said, “My case ended up feeling like a mild flu that lasted for two weeks. And then it faded after that.”
Listen to James Hamblin interview Kola and Mahajan on an episode of Social Distance, The Atlantic’s podcast about life in the pandemic:
“There’s a big difference in how people handle this virus,” says Robert Murphy, a professor of medicine and the director of the Center for Global Communicable Diseases at Northwestern University. “It’s very unusual. None of this variability really fits with any other diseases we’re used to dealing with.”
This degree of uncertainty has less to do with the virus itself than how our bodies respond to it. As Murphy puts it, when doctors see this sort of variation in disease severity, “that’s not the virus; that’s the host.” Since the beginning of the pandemic, people around the world have heard the message that older and chronically ill people are most likely to die from COVID-19. But that is far from a complete picture of who is at risk of life-threatening disease. Understanding exactly how and why some people get so sick while others feel almost nothing will be the key to treatment.
Hope has been put in drugs that attempt to slow the replication of the virus—those currently in clinical trials like remdesivir, ivermectin, and hydroxychloroquine. But with the flu and most other viral diseases, antiviral medications are often effective only early in the disease. Once the virus has spread widely within our body, our own immune system becomes the thing that more urgently threatens to kill us. That response cannot be fully controlled. But it can be modulated and improved.
One of the common, perplexing experiences of COVID-19 is the loss of smell—and, then, taste. “Eating pizza was like eating cardboard,” Mahajan told me. Any common cold that causes congestion can alter these sensations to some degree. But a near-total breakdown of taste and smell is happening with coronavirus infections even in the absence of other symptoms.
Jonathan Aviv, an ear, nose, and throat doctor based in New York, told me he has seen a surge in young people coming to him with a sudden inability to taste. He’s unsure what to tell them about what’s going on. “The non-scary scenario is that the inflammatory effect of the infection is temporarily altering the function of the olfactory nerve,” he said. “The scarier possibility is that the virus is attacking the nerve itself.” Viruses that attack nerves can cause long-term impairment, and could affect other parts of the nervous system. The coronavirus has already been reported to precipitate inflammation in the brain that leads to permanent damage.
Though SARS-CoV-2 (the new coronavirus) isn’t reported to invade the brain and spine directly, its predecessor SARS-CoV seems to have that capacity. If nerve cells are spared by the new virus, they would be among the few that are. When the coronavirus attaches to cells, it hooks on and breaks through, then starts to replicate. It does so especially well in the cells of the nasopharynx and down into the lungs, but is also known to act on the cells of the liver, bowels, and heart. The virus spreads around the body for days or weeks in a sort of stealth mode, taking over host cells while evading the immune response. It can take a week or two for the body to fully recognize the extent to which it has been overwhelmed. At this point, its reaction is often not calm and measured. The immune system goes into a hyperreactive state, pulling all available alarms to mobilize the body’s defense mechanisms. This is when people suddenly crash.
Bootsie Plunkett, a 61-year-old retiree in New Jersey with diabetes and lupus, described it to me as suffocating. We met in February, taping a TV show, and she was her typically ebullient self. A few weeks later, she developed a fever. It lasted for about two weeks, as did the body aches. She stayed at home with what she presumed was COVID-19. Then, as if out of nowhere, she was gasping for air. Her husband raced her to the hospital, and she began to slump over in the front seat. When they made it to the hospital, her blood-oxygen level was just 79 percent, well below the point when people typically require aggressive breathing support.
Such a quick decline—especially in the later stages of an infectious disease—seems to result from the immune response suddenly kicking into overdrive. The condition tends to be dire. Half of the patients with COVID-19 who end up in the intensive-care unit at New York–Presbyterian Hospital stay for 20 days, according to Pamela Sutton-Wallace, the regional chief operating officer. (In normal times, the national average is 3.3 days). Many of these patients arrive at the hospital in near-critical condition, with their blood tests showing soaring levels of inflammatory markers. One that seems to be especially predictive of a person’s fate is a protein known as D-dimer. Doctors in Wuhan, China, where the coronavirus outbreak was first reported, have found that a fourfold increase in D-dimer is a strong predictor of mortality, suggesting in a recent paper that the test “could be an early and helpful marker” of who is entering the dangerous phases.
These and other markers are often signs of a highly fatal immune-system process known as a cytokine storm, explains Randy Cron, the director of rheumatology at Children’s of Alabama, in Birmingham. A cytokine is a short-lived signaling molecule that the body can release to activate inflammation in an attempt to contain and eradicate a virus. In a cytokine storm, the immune system floods the body with these molecules, essentially sounding a fire alarm that continues even after the firefighters and ambulances have arrived.
At this point, the priority for doctors shifts from hoping that a person’s immune system can fight off the virus to trying to tamp down the immune response so it doesn’t kill the person or cause permanent organ damage. As Cron puts it, “If you see a cytokine storm, you have to treat it.” But treating any infection by impeding the immune system is always treacherous. It is never ideal to let up on a virus that can directly kill our cells. The challenge is striking a balance where neither the cytokine storm nor the infection runs rampant.
Cron and other researchers believe such a balance is possible. Cytokine storms are not unique to COVID-19. The same basic process happens in response to other viruses, such as dengue and Ebola, as well as influenza and other coronaviruses. It is life-threatening and difficult to treat, but not beyond the potential for mitigation.
At Johns Hopkins University, the biomedical engineer Joshua Vogelstein and his colleagues have been trying to identify patterns among people who have survived cytokine storms and people who haven’t. One correlation the team noticed was that people taking the drug tamsulosin (sold as Flomax, to treat urinary retention) seemed to fare well. Vogelstein is unsure why. Cytokine storms do trigger the release of hormones such as dopamine and adrenaline, which tamsulosin can partially block. The team is launching a clinical trial to see if the approach is of any help.
One of the more promising approaches is blocking cytokines themselves—once they’ve already been released into the blood. A popular target is one type of cytokine known as interleukin-6 (IL-6), which is known to peak at the height of respiratory failure. Benjamin Lebwohl, director of research at Columbia University’s Celiac Disease Center, says that people with immune conditions like celiac and inflammatory bowel disease may be at higher risk of severe cases of COVID-19. But he’s hopeful that medications that inhibit IL-6 or other cytokines could pare back the unhelpful responses while leaving others intact. Other researchers have seen promising preliminary results, and clinical trials are ongoing.
If interleukin inhibitors end up playing a significant role in treating very sick people, though, we would run out. These medicines (which go by names such as tocilizumab and ruxolitinib, reading like a good draw in Scrabble) fall into a class known as “biologics.” They are traditionally used in rare cases and tend to be very expensive, sometimes costing people with immune conditions about $18,000 a year. Based on price and the short supply, Cron says, “my guess is we’re going to rely on corticosteroids at the end of the day. Because it’s what we have.”
That is a controversial opinion. Corticosteroids (colloquially known as “steroids,” though they are of the adrenal rather than reproductive sort), can act as an emergency brake on the immune system. Their broad, sweeping action means that steroids involve more side effects than targeting one specific cytokine. Typically, a person on steroids has a higher risk of contracting another dangerous infection, and early evidence on the utility of steroids in treating COVID-19, in studies from the outbreak in China, was mixed. But some doctors are now using them to good effect. Last week, the Infectious Diseases Society of America issued guidelines on steroids, recommending them in the context of a clinical trial when the disease reaches the level of acute respiratory distress. They may have helped Plunkett, the 61-year-old from New Jersey. After three days on corticosteroids, she left the ICU—without ever being intubated.
Deciding on the precise method of modulating the immune response—the exact drug, dose, and timing—is ideally informed by carefully monitoring patients before they are critically ill. People at risk of a storm could be monitored closely throughout their illness, and offered treatment immediately when signs begin to show. That could mean detecting the markers in a person’s blood before the process sends her into hallucinations—before her oxygen level fell at all.
In typical circumstances in the United States and other industrialized nations, patients would be urged to go to the hospital sooner rather than later. But right now, to avoid catastrophic strain on an already overburdened health-care system, people are told to avoid the hospital until they feel short of breath. For those who do become critically ill and arrive at the ER in respiratory failure, health-care workers are then behind the ball. Given those circumstances, the daily basics of maintaining overall health and the best possible immune response become especially important.
The official line from the White House Coronavirus Task Force has been that “high-risk” people are older and those with chronic medical conditions, such as obesity and diabetes. But that has proven to be a limited approximation of who will bear the burden of this disease most severely. Last week, the Centers for Disease Control and Prevention released its first official report on who has been hospitalized for COVID-19. It found that Latinos and African Americans have died at significantly higher rates than white Americans. In Chicago, more than half of the people who have tested positive, and nearly 60 percent of those who have died, were African American. They make up less than one-third of the city’s population. Similar patterns are playing out across the country: Rates of death and severe disease are several times higher among racial minorities and people of low socioeconomic status.
These disparities are beginning to be acknowledged at high levels, but often as though they are just another one of the mysteries of the coronavirus. At a White House briefing last week, Vice President Mike Pence said his team was looking into “the unique impact that we’re seeing reported on African Americans from the coronavirus.” Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, has noted that “we are not going to solve the issues of health disparities this month or next month. This is something we should commit ourselves for years to do.”
While America’s deepest health disparities absolutely would require generations to undo, the country still could address many gaps right now. Variation in immune responses between people is due to much more than age or chronic disease. The immune system is a function of the communities that brought us up and the environments with which we interact every day. Its foundation is laid by genetics and early-life exposure to the world around us—from the food we eat to the air we breathe. Its response varies on the basis of income, housing, jobs, and access to health care.
The people who get the most severely sick from COVID-19 will sometimes be unpredictable, but in many cases, they will not. They will be the same people who get sick from most every other cause. Cytokines like IL-6 can be elevated by a single night of bad sleep. Over the course of a lifetime, the effects of daily and hourly stressors accumulate. Ultimately, people who are unable to take time off of work when sick—or who don’t have a comfortable and quiet home, or who lack access to good food and clean air—are likely to bear the burden of severe disease.
Much is yet unknown about specific cytokines and their roles in disease. But the likelihood of disease in general is not so mysterious. Often, it’s a matter of what societies choose to tolerate. America has empty hotels while people sleep in parking lots. We are destroying food while people go hungry. We are allowing individuals to endure the physiological stresses of financial catastrophe while bailing out corporations. With the coronavirus, we do not have vulnerable populations so much as we have vulnerabilities as a population. Our immune system is not strong.
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