Four Lifestyle Interventions to Help You Avoid Severe COVID-19
“An ounce of prevention is worth a pound of cure.” Benjamin Franklin
Setting the Scene
Unfortunately, COVID-19 has become a highly polarized topic. As a result, I have received plenty of online hate for publishing articles on social media about COVID-19.
So before we begin, I want to state for the record that this article is not about vaccination, it’s about lifestyle interventions to help you maximize your natural immune response against viruses.
Finally, I wrote this article for everyone, irrespective of whether you are pro-vaccine, anti-vaccine, or vaccine-hesitant.
The Overall Aim
The purpose of this article is to put you in the best possible position to fight off a SARS-CoV-2 infection, independently of your vaccine status.
To do this, I am hoping to achieve two broad aims.
The first aim is to help reduce your levels of chronic inflammation.
Chronic inflammation is a hallmark of many known risk factors for severe COVID-19 (1). Therefore, lowering your level of chronic inflammation may reduce the risk of triggering the hyper-inflammatory response that is so dangerous for COVID-19 patients.
The second aim is to strengthen your immune system to mount a robust and specific immune response against the SARS-CoV-2 virus should you become infected.
Intervention One: Nutrition
Recently, researchers have highlighted how poor nutrition increases your risk of suffering severe COVID-19 (2-7). Table One summarises the data from three studies that show how mortality risk changes with nutritional status (3, 5, 7).
|Study||Normal Nutrition (Mortality %)||Moderate Malnutrition (Mortality %)||Severe Malnutrition (Mortality %)|
|Wei et al||0%||5%||6.5%|
|Çınar et al||1%||4.1%||25.5%|
|Zhao et al||0%||13%||43.2%|
A Simple Approach For Optimal Nutrition
I’m a massive fan of the MIND diet (8). I’ll be writing a detailed article on the MIND diet soon. But, for now, refer to Table Two for a simple overview of the diet to get you going.
|Mainly Eat These Foods||Try to Avoid These Foods|
|Green Leafy Vegetables: 6 or more servings a week |
Other Vegetables: 1 or more servings a day
Nuts: 5 servings a week
Berries: 2 or more servings a week
Beans: 3 or more servings a week
Whole Grains: 3 servings a day
Fish (not fried): one or more meals a week
Poultry (not fried): two or more meals per week
Olive Oil: the primary source of fat in the diet
Wine: One glass per day
|Red Meats |
Butter and Stick Margarine
Pastries and Sweets
Fried or Fast Foods
Table Two. Primary Food Groups and Recommended Servings of the Mind Diet
The consumption of leafy green vegetables, other vegetables, berries, and nuts provide essential vitamins and micronutrients (9). They also offer fiber that is critical for gut health (see below).
Fish, poultry, and beans provide protein (9).
Whole grains offer a metabolically friendly source of carbohydrates. In addition, consistent with our recent article on beer, moderate wine consumption improves the function of your immune system (9).
Supplementing with Vitamins and Micronutrients
Deficiencies in essential micronutrients increase your risk of disease and death from viral infection (10).
It would be best to get all of your nutrients through eating a balanced and healthy diet. The critical point is that supplementation is only required if you are deficient in one or more micro-nutrients or vitamins.
However, there are a surprising number of people that are micro-nutrient deficient.
For example, within the US population, 45% of people are low in vitamin A, 46% for vitamin C, 95% for vitamin D, 84% for vitamin E, and 15% for zinc (9). Further, older adults are far more likely to be deficient in vitamins essential for optimal immune function.
Because vitamin deficiency increases your risk of viral infection (10), supplementation may help protect you from severe COVID-19.
Vitamin C, vitamin D, and zinc are the micronutrients with the most robust evidence for immune support (10).
Vitamin D and COVID-19
People infected with SARS-CoV-2 had lower serum vitamin D than people not infected with the virus, suggesting that adequate vitamin D protects you from SARS-CoV-2 infection (11).
Concerning COVID-19 disease outcome, there is a trend between people with low serum vitamin D and (i) increased Covid-10 disease severity, (ii) increased need for intensive care, (iii) increased requirement for forced ventilation, and (iv) increased risk of mortality (11).
Unfortunately, these results did not reach statistical significance due to the poor quality of the studies analyzed. However, the overall trend does support a role for vitamin D in protecting you from severe COVID-19.
Two of the three clinical trials analyzed showed that vitamin D supplementation reduced disease severity, with no effect on the third trial (11).
Collectively, the combined data support vitamin D supplementation as a way for you to avoid infection and also reduce the severity of COVID-19 if you become infected (11).
Zinc and COVID-19
You need to maintain adequate levels of zinc for your immune system to work effectively.
For this reason, zinc deficiency makes people more vulnerable to intestinal and respiratory infections. Unfortunately, the elderly, vegans and vegetarians, and individuals with chronic diseases are often deficient in zinc.
Multiple clinical trials have shown that zinc supplementation shortens the duration of the common cold (12). In addition, there are good reasons to believe that zinc supplementation also protects you from severe COVID-19 (13, 14). Indeed, the only clinical trial performed to date showed that zinc supplementation improved COVID-19 outcomes (15).
Thus, the collective data support the hypothesis that zinc supplementation is protective against severe COVID-19.
Vitamin C and COVID-19
Vitamin C is interesting. Although most people believe that vitamin C protects you against respiratory viral infections, this is generally not the case. Analysis of 24 clinical trials showed that vitamin C supplementation at 200 mg/day did not reduce the common cold incidence (16). However, although the effects weren’t dramatic, vitamin C supplementation did tend to shorten the duration and severity of colds (16).
It’s a different story in athletes. For example, in marathon runners, skiers, and soldiers on sub-arctic exercises, vitamin C supplementation reduced the incidence of colds by a whopping 52% (16)!
Thus, even if you are sedentary, vitamin C supplementation likely has some benefit in protecting you from COVID-19. Crucially, vitamin C supplementation may provide significant protection against COVID-19 and other viruses if you are training hard or competing at a high level in sport.
Take-Home Message Number One
You can reduce the chance of succumbing to severe COVID-19 by improving your nutrition and ensuring that you are not deficient in essential vitamins and minerals, particularly zinc, vitamin C, and vitamin D.
Intervention Two: Gut Health
What is a healthy gut?
Your gut is a complex ecosystem consisting of millions of bacteria, collectively known as your gut microbiome. Don’t freak out, but your gut microbiome can weigh up to 2 kg!
A healthy gut microbiome plays a critical role in maintaining your health (17). Briefly, a healthy gut microbiome provides the following beneficial functions (17):
- Improved metabolic health
- Produce critical bacterial metabolites, such as short-chain fatty acids (SCFAs), helping to support your immune system
- Preserves the structural integrity of the gut mucosal barrier
- Protects you against pathogens
In contrast, having an unhealthy gut microbiota is a state called dysbiosis. People with dysbiosis have a less diverse and less stable bacterial population that often includes pathogenic bacteria (17).
Dysbiosis has many adverse consequences, such as poor metabolic health and a compromised gut mucosal barrier. In addition, the reduced gut barrier integrity caused by dysbiosis allows bacteria and toxins to enter your bloodstream, triggering an inflammatory response that may exacerbate the risk of severe COVID-19 (18).
The Gut-Lung Axis
There is increasing evidence that your gut microbiome affects your lung health (19). For example, gut dysbiosis contributes to asthma, tuberculosis, and lung cancer (19). However, how the lungs and gut communicate is still not fully understood.
Nevertheless, a distributed ‘mucosal immune response’ exists where the gut microbiome influences your immune response at distal mucosal sites, such as the lung. Notably, several studies indicate that dysbiosis can increase the severity of respiratory virus infections, such as influenza (20).
Thus, maintaining your gut health may protect you against the effects of respiratory viruses.
The link between Dysbiosis and Severe COVID-19
Several risk factors for severe COVID-19, such as age, diabetes, and hypertension, are associated with gut dysbiosis (21). In addition, SARS-CoV-2 infected patients who developed COVID-19 disease have significantly different gut microbiomes compared with asymptomatic SARS-CoV-2 patients (18).
Furthermore, new evidence suggests that suffering a SARS-CoV-2 gut infection can lead to dysbiosis (22). Moreover, the dysbiosis caused by COVID-19 disease may persist long after the SARS-CoV-2 infection has cleared, as shown in a recent study that demonstrated dysbiosis persisting in COVID-19 survivors 3 months after their infection had cleared (23).
Thus dysbiosis may be a risk factor for COVID-19 and long COVID.
Why Gut Health is Important for Avoiding COVID-19
To summarize the story so far, actively maintaining your gut health may be protective against COVID-19 for the following reasons.
- A healthy gut reduces inflammation, which could help you avoid a severe inflammatory response to a SARS-CoV-2 infection.
- Gut dysbiosis makes other respiratory virus infections, such as influenza, more severe. Therefore, gut dysbiosis may increase the risk of severe COVID-19 after SARS-CoV-2 infection.
- Associations between gut microbiota composition and inflammatory markers in patients with COVID-19 suggest that an unhealthy gut microbiome increases the risk of COVID-19 (18).
- COVID-19 can cause dysbiosis, which can last several months after SARS-CoV-2 infection (18, 23).
Therefore, COVID-19-induced dysbiosis may increase the risk of long-COVID (18, 23).
Thus, although researchers have not yet formally established the link between gut health and COVID-19 in randomized clinical trials, there are good reasons for you to believe that maintaining a healthy gut helps protect you against COVID-19.
Four Ways to Maximise Your Gut Health
Fortunately, there are safe and effective ways for you to improve and maintain your gut health.
The best and most important intervention to improve and maintain your gut health is following a healthy diet (24, 25). In a nutshell, maintaining a nutrient-rich diet with plenty of fiber maintains a diverse gut microbiome that helps keep you healthy (25).
We recommend two diet options: the MIND diet and the Mediterranean diet, which provide a large proportion of mixed vegetables and unsaturated fats to support a healthy gut microbiome.
However, any diet low in saturated fat and high in plant material, particularly fiber, supports a healthy gut microbiome (25).
Prebiotics are nutrients that preferentially support the growth and proliferation of beneficial bacteria in your gut (26). Prebiotics are present in leek, asparagus, chicory, Jerusalem artichoke, garlic, artichoke, onion, and banana (26).
Of course, you can readily supplement your diet with prebiotics or consume prebiotic-fortified foods and supplements to help maintain a healthy gut biome (26).
A probiotic is a ‘live micro-organisms that, when administered in adequate amounts, confer a health benefit on the host’ (27). Some established positive effects of probiotic consumption are protection against gastroenteritis, improved lactose tolerance, stimulation of the immune system, and reductions in blood lipids (26).
In humans, the most common forms of probiotics are fermented milk products (e.g., yogurt) and freeze-dried preparations of beneficial bacteria in capsules (26).
Multiple, carefully controlled animal studies have shown that aerobic exercise changes the gut microbiome and increases the production of bacterial metabolites that increase the gut barrier’s integrity and support healthy immune function (28). In addition, studies in humans support the idea that regular exercise supports a healthy gut microbiome.
However, there are several caveats to using exercise for improving your gut health.
First, the effects of exercise on your gut microbiome disappear if you stop exercising (28). Second, exercise has the most beneficial effects for improving gut microbiome health in lean individuals (28). Finally, although a short duration of light-to-moderate aerobic training may improve your gut microbiome, a longer duration at a higher intensity may be required to induce significant improvements in your gut microbiome composition (28).
Thus, lean individuals who train hard for extended periods experience the most significant improvements to their gut health (28).
Take-Home Message Two
Interventions such as following a healthy diet, prebiotic and probiotic supplementation, and aerobic exercise are safe and effective options for improving your gut health and reducing the risk of severe COVID-19.
Intervention Three: Exercise
Exercise reduces your risk of acquiring a respiratory viral infection in the community (29) and dying from a respiratory virus if you become infected (29).
But what about SARS-CoV-2, the virus responsible for the COVID-19 pandemic?
A recent article published in the British Journal of Sports Medicine looked at how physical activity protected 48 440 adult patients diagnosed with COVID-19 (30).
Specifically, they linked physical activity (classified as inactive = 0 – 10 min/week, some activity=11 – 149 min/week, consistently meeting guidelines = 150 + min/week) to the risk of (i) hospitalization, (ii) intensive care admission and (iii) death after COVID-19 diagnosis (30).
The results of their analysis are striking.
Patients with COVID-19 who were consistently inactive had (i) a 2.26 elevated risk of hospitalization, (ii) a 1.73 increase in the risk of admission to intensive care, and (iii) a 2.49 increase in the risk of death due to COVID-19 compared to COVID-19 diagnosed patients who consistently met physical activity guidelines (30).
To quote the Authors directly:
‘The magnitude of risk for all outcomes associated with being consistently inactive exceeded the odds of smoking and virtually all the chronic diseases studied in this analysis, indicating physical inactivity may play a crucial role as a risk factor for severe COVID-19 outcomes’ (30).
The authors conclude that ‘Pandemic control recommendations should include regular physical activity across all population groups’ (30).
The Long-Term Protective Effects of Exercise Against COVID-19
A second study has revealed the remarkable long-term protective effect of physical fitness. Here, the Author’s assessed how physical fitness at a young age protects you against disease many years later.
First, the Authors retrieved over one million Swedish men’s cardio-respiratory fitness (CRF) levels while serving in the military between 1968 and 2005. Then, they assessed how the historic CRF values affected the risk of hospitalization, intensive care, or dying due to COVID-19 in 2020 (31).
Strikingly, high cardiorespiratory fitness at a young age reduces the risk of COVID-19 hospitalization by 24%, intensive care by 39%, and death by 44% (31). In addition, the protective effect of physical fitness against severe COVID-19 occurred in people of all ages, weights, and despite the presence of chronic disease (31).
Thus, cardiorespiratory fitness at a young age protects people later in life against severe COVID-19.
How to Exercise for Maximal COVID-19 Protection
The most protection against COVID-19 occurs in people who have performed at least 150 minutes per week of moderate exercise targeting the cardiorespiratory system (30, 31).
Although strength training offers some protection against COVID-19, aerobic fitness appears far more effective (30, 31). Thus, we recommend that improving your aerobic fitness should become a priority in your training program.
However, training sessions that last longer than one hour become stressful on your body, which can suppress your immune system (32). For this reason, you should train as efficiently as possible to get your workout done in under an hour. A straightforward approach is to perform four 40-minute sessions of cardio four days a week.
Currently, there are no clear recommendations on which type of training is optimal. However, steady-state cardio, high-intensity interval training (HIIT), or sprint interval training (SIT) improve cardiorespiratory fitness. So, pick the type of training you enjoy most.
Unfortunately, it takes time to improve your fitness levels for virus protection. For example, it took 20 weeks of regular exercise to observe an improvement in the immune response in patients (29). Thus, although exercise helps protect you against viral disease, it’s not a quick fix.
Take-Home Message Three
Cardiorespiratory fitness appears to provide long-term protection against COVID-19 despite the presence of other risk factors, such as obesity and chronic disease (31).
For these reasons, you should perform 3-5 workouts consisting of moderate physical activity each week, keeping each session to under one hour.
Intervention Four: Sleep
The importance of sleep for your immune response is evident when we consider the effect of sleep deprivation on vaccine response.
For example, reducing your sleep four days before an influenza vaccination can reduce your antibody production from the flu vaccine by over 50% (reviewed in (33)).
Furthermore, suppose you don’t sleep the night after receiving a hepatitis-A, hepatitis-B, or influenza vaccine. In that case, you also reduce your antibody response to the vaccine by about 50% (reviewed in (33)).
Thus, being sleep deprived either before or immediately after receiving your vaccine reduces the vaccine’s protective effect.
Sleep and COVID-19 Vaccine Response
Does sleep quality impact your immune response to the SARS-CoV-2 vaccine?
Unfortunately, we currently don’t have a definitive answer to this question (34). However, given how sleep deprivation negatively impacts the efficacy of other vaccines, it is likely that disrupted sleep reduces the effectiveness of the COVID-19 vaccine (34).
Maximizing your immune response to the COVID-19 is very important for three reasons.
First, for those of you who have a compromised immune system (for example, people over the age of 70), ensuring you are sleeping well before and after your vaccine may be necessary to provide a protective immune response post-vaccination (34).
Second, the emergence of Sars-CoV-2 variants that can now partially avoid the vaccine immune response means that everyone should maximize their immune response to the COVID-19 vaccine.
Finally, some researchers have found that antibody responses rapidly wane after COVID-19 vaccination (35).
Now, before you panic, it’s normal for antibody levels to decline after any virus infection. Remember, it’s the memory cells of your immune system that provide long-lasting protection, not your short-lived antibody response. Nevertheless, a more robust antibody response after your vaccine produces more memory immune cells, which reduces your chance of infection (35).
Thus, the current recommendation is that you should focus on getting as much quality sleep as possible before and after your COVID-19 vaccination (35, 36).
Sleep and Virus Infection
It should come as no surprise that sleep is also crucial for protecting you from infection.
For example, people who report poor sleep are more likely to suffer from respiratory diseases and succumb to pneumonia than those who experience adequate sleep (reviewed in (33)).
In addition, those who experience disrupted sleep report experiencing more frequent cold, influenza, and gastro infections than those who sleep well (reviewed in (33)).
Finally, virus challenge experiments show that people who experienced impaired sleep had an increased chance of developing a cold after receiving cold virus nasal drops (reviewed in (33)).
Thus, disrupted sleep makes you vulnerable to virus infections.
Sleep and COVID-19 Disease
Unfortunately, the role between sleep and COVID-19 remains understudied. Currently, the only known link between sleep and COVID-19 is the link between sleep apnea and severe COVID-19.
Obstructive sleep apnea (OSA) is a sleep breathing disorder caused by obstructions of the upper airway during sleep (37). Recently, researchers identified OSA as a risk factor for severe COVID-19 (38).
Given that chronic sleep disruption increases inflammation and reduces anti-viral immunity (35), it makes sense that the presence of OSA can tip patients towards the state of runaway inflammation that increases the severity of COVID-19 (33).
Thus, it’s likely that sleep disruption increases your risk of suffering severe COVID-19.
Melatonin is produced in the brain during periods of darkness and is an essential regulator of your sleep-wake cycle (a.k.a, your circadian rhythm) (39).
The sleep-related roles of melatonin are promoting sleep, maintaining sleep, resetting your circadian clock, and training your circadian rhythm over time (39). Unfortunately, your natural melatonin production declines as you age, which contributes to age-related insomnia.
In addition, melatonin has several non-sleep-related roles in maintaining your health. For example, melatonin is an antioxidant, has anti-inflammatory effects, and is neuro- and cardio-protective (39-41).
When taken as a drug, melatonin appears to be a safe and effective sleep aid (42). Furthermore, the additional biological effects of melatonin mean that it may offer additional protection against COVID-19 (43).
Before you rush to the chemist to stock up on melatonin, please check with your doctor. Because various melatonin formulations are available, matching the correct melatonin formulation to your specific sleep disruption produces optimal sleep results (43).
Only your doctor can identify which melatonin formulation is suitable for you.
Take-Home Message Four
High-quality sleep is vital to protect you against virus infection. In contrast, disrupted sleep increases chronic inflammation, makes you vulnerable to viral infection, and dampens your vaccine immune response. For these reasons, getting consistent, high-quality sleep is an essential part of your COVID-19 defenses.
By focusing on optimizing your diet, keeping your gut healthy, building a cardiovascular fitness base, and getting consistent, high-quality sleep, you are tipping the odds in your favor for avoiding severe COVID-19.
In addition, this approach also protects you from other respiratory viruses, such as influenza.
References and Further Reading
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- M. C. Morris et al., MIND diet slows cognitive decline with aging. Alzheimers Dement 11, 1015-1022 (2015).
- S. Cohen, Psychosocial Vulnerabilities to Upper Respiratory Infectious Illness: Implications for Susceptibility to Coronavirus Disease 2019 (COVID-19). Perspect Psychol Sci 16, 161-174 (2021).
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Frailty is preventable, and often reversible, if you are willing to put in the work and follow the three golden rules of resistance training.
Frailty is preventable, and often reversible, if you are willing to put in the work and follow the three golden rules of resistance training.