Covid-19 has been the story of 2020 and continues to look like it will be around for the foreseeable future impacting people worldwide. While it may sound like you can’t do anything about the virus outside the typical public health recommendations of masking, social distancing, and washing your hands, there is so much more you can do to reduce your risk of contracting the virus and having severe complications from the disease.
Unfortunately the only thing that seems to be discussed in the media is the progress of various pharmaceutical treatments and a vaccine. While developments in these things would be a huge relief we are now over 7 months into the introduction of this virus and nobody knows how much longer we will have to wait for a breakthrough. If you had been working on the risk factors you could control over these last 7 months you could have greatly decreased your susceptibility to the virus and provided yourself with greater resilience if you did happen to contract it.
While you will often hear how age seems to be one of the biggest predictors of your outcome to the virus, the majority of the other predictive factors are things you can do something to change. These include primarily lifestyle choices such as exercise, nutrition, sleep, and stress management. If you had done things to improve these factors you would be much better off today than you were when this all started.
Instead, with the prevalent lockdown guidelines and large rates of unemployment most people were getting less sleep, eating less healthy foods, and being less active in general as well as having higher levels of stress and social isolation. This is not good because even if a successful vaccine is developed, part of the response to it relies on a healthy host and immune system.
Obesity, sleep disturbances, and poor microbiome health can all result in less vaccine induced immunity. The good news though is that if you start modifying these things now you can significantly improve your health in as little as two weeks.
Modifiable Risk Factors
1. Exercise
Maintaining a regular exercise routine is one of the most critical things you can do to benefit your health and reduce your risk of diseases. Aerobic exercise is beneficial in particular for improvements in cardiovascular function and improved resilience against infections. Outside of the physical benefits exercise also shows significant benefits to mental health including reduced symptoms of depression and anxiety which have been increasing during this period of social distancing. Obesity, high blood pressure, and diabetes are the biggest risk factors for severe Covid-19 infection and exercise plays a crucial role in managing and improving these conditions.
Exercise has been shown to be beneficial and well-tolerated in older individuals even in cases of acute hospital admission. In one trial they compared two groups of people admitted to the hospital intensive care unit (ICU) and had one group participate in a twice daily resistance, balance, and walking intervention during their stay. The exercise group had improved outcomes on all functional and cognitive tests as well as a self reported improved quality of life standards – there were also no adverse events in the exercise group showing great safety even in patients ill enough to be in the ICU. Exercise has shown numerous benefits in every chronic disease state and with proper “dosages” is extremely safe.
While some form of aerobic activity is probably most beneficial in improving markers of immune function and increasing resistance to bacterial and viral infections other modes of exercises should also be included in a regular routine for positive effects on mobility, balance, and strength as well as mental health and well-being. Current recommendations were for individuals to get 150-300 minutes per week or aerobic exercise divided between 5 days as well as 2-3 days of resistance and balance training. It also has been recommended during this quarantine time to increase activity to 200-400 minutes per week divided among 5-7 days to account for the decrease in normal daily activity levels in non-quarantine conditions. Some form of mobility/flexibility training should also be included on all training days to maintain orthopedic health. This training should be primarily done at lower to moderate intensities which have been shown to positively affect immune health with vigorous activity being planned carefully due to more intense exercise having a short term decrease in immune function.
Exercise Action Strategies:
Minimum Dose: Go for a walk (preferably outside)
- The simplest exercise strategy you can add if you’re starting from nothing is simply going for a walk. As little as 10 minutes can be beneficial especially after meals as it can help improve blood sugar management. Ideally you can do this outdoors to also reap the benefits of sunlight for vitamin D and stress reduction and blood pressure benefits of forest bathing. Try to get out and walk for 10 minutes after each meal or try to accumulate at least 10,000 steps per day.
Moderate Dose: Walks after meals and 1-2 circuit workouts/week
- If you would like to get further benefits from exercise but are still somewhat limited on time continue the daily walking after meals and add in some circuit training sessions 1-2x per week. Even a 10 minute workout can provide benefits to your cardiovascular system and muscular strength if you are limited on time. Limiting the rest periods and moving through a couple exercises in a circuit will save time while getting your heart rate up. Pick up to 4 exercises (such as jumping jacks, squats, pushups, step-ups, etc.) and go through them one after the other resting after all are completed. After a short rest repeat the circuit. This can be done as many times as your time restraints allow from 4 minutes up to 30 minutes.
High Dose: Walks after meals, meet activity recommendations
- If time is less of an issue for you getting more exercise up to a point is going to be more beneficial for your overall health. Continue to perform daily walking after meals and add workouts to reach the activity recommendations which are at least 300 minutes of moderate intensity activity per week with 2-3 resistance training sessions. Walking, biking, running, swimming, and really any other type of cardiovascular exercise can count towards this and it would equate to at least 30 minutes, 6 days per week. Include 2-3 resistance training sessions weekly depending on what equipment you have access to – body weight workouts are completely fine and can be just as beneficial as weight training.
2. Nutrition
While many people have gravitated to poorer food choices throughout this pandemic, now is the time it’s even more important to make healthier choices to improve your immune system. Grocery stores were pretty bare for a few weeks to months in the beginning and it may have been harder to make healthy choices but that is no longer the case. Even in the beginning there were still options available that were healthy and affordable if you knew what to look for. There are also certain nutrients that have been associated specifically with improved outcomes in Covid-19 so far including vitamin D, zinc, and selenium. Fermented foods and probiotics may also provide benefit as a significant portion of the immune system resides in the gut and relies on this collection of bacteria to provide important signals for overall health and immunity.
Important nutritional factors to keep an eye on during cold and flu season and the current coronavirus climate is to avoid high amounts of sugar and processed vegetable oils especially. Vegetable oils and sugar will contribute to higher levels of inflammation in the body and worsening of markers of cardiovascular function which can predispose you to a worse outcome if you do contract an infection. You should also keep alcohol consumption to a minimum as alcohol can depress immune function whether ingested acutely or chronically in higher doses. Basing your diet around unprocessed foods including meat, seafood, eggs, vegetables, and fruit will supply you with crucial vitamins and minerals which can be rounded out with supplementation if any deficits are found. Getting a variety of colored fruits and vegetables as well as beverages like coffee and green tea may also help provide a good dose of antioxidant compounds that will help bolster your immune system.
While very little has been studied in the context of Covid-19 there are a number of supplements that have shown to be helpful in combating other bacterial and viral infections including various flu strains. Most of these work by providing support to the immune system and increasing levels of antioxidant defense chemicals throughout the body which can help reduce the likelihood of severe acute respiratory distress syndrome (ARDS), the common fatal complication with Covid-19 infection. Glutathione is an antioxidant compound found throughout all cells in the body that helps neutralize inflammation and other harmful compounds. Levels typically decline with age and can also be reduced with poor nutrition, environmental toxins, and stress which may be one reason advancing age is such a strong predictor of poorer Covid-19 outcomes. A number of studies have utilized either intravenous glutathione or supplements that increase circulating levels of this molecule in the body, such as N-acetylcysteine (NAC), to decrease the inflammatory cascade present in more severe Covid-19 cases as well as other respiratory illnesses.
Nutrition Action Strategies:
Minimum Dose: Add in 1-2 veggies/fruits to your daily meals
- Starting from square one you may simply add 1-2 daily servings of vegetables or fruit to each meal. Depending on what you choose different sources will contain different beneficial compounds that can help with the body’s antioxidant defense system. The fiber in these foods can also help reduce hunger and aid in weight loss by decreasing the volume of food you are eating and likelihood of reaching for less healthy snacks throughout the day due to being less hungry.
Moderate Dose: Consume 30+ grams of protein per meal with 3+ different veggies/fruits daily, eliminate sugar and vegetable oils
- Continue to try and include vegetables and fruits in each meal and choose at least 3 different options to get a variety of nutrients. To further aid with weight control and reducing hunger include at least 30 grams of a quality protein source (beef, fish, chicken, eggs) at each meal. Most diets succeed not necessarily due to what you are eating, but what you aren’t eating. Everyone will benefit from eliminating processed vegetable oils and sugar from their diet to improve your overall health and energy levels.
High Dose: Consume protein and veggies/fruits at each meal, eliminate sugar/vegetable oils, targeted supplementation for immune optimization
- To provide maximum benefits you want to include adequate protein, eliminate vegetable oils and sugar, and have vegetables and/or fruit with every meal. If you are meeting all of these goals targeted supplementation with specific nutrients can ensure your highest level of immunity. The key nutrients to consider supplementation for include vitamin D/K2, zinc, selenium, and magnesium. Other things that may be beneficial are garlic, vitamin C, mushrooms, and N-acetylcysteine. Always consult your doctor before taking any herbal supplements to make sure there are no potential drug interactions if you are on any prescription medications.
3. Sleep
The importance of sleep has been becoming more mainstream over the last couple years and definitely applies to current events as well. Sleep plays a significant role in regulating healthy weight, improving mental health and energy levels, and maintaining a strong immune system. Both acute and chronic sleep deprivation have been shown to reduce the immune response to vaccination and can elevate multiple blood markers of inflammation and oxidative stress. Reduced sleep also negatively affects hormone levels that help the body regulate hunger and avoid overeating which can lead to weight gain over time.
When you miss out on sleep your body does not produce or release as much of a chemical called cytokines which help target infection and inflammation. Because of the importance of sleep in maintaining a healthy immune system it is important to try and keep a consistent sleep pattern even if your schedule changed due to the pandemic. Having a set bedtime and wake up time is important so that your body keeps a regular circadian rhythm and this can even help you have steady energy levels during the day. Developing a good routine before bed can also help ensure quality sleep at night that helps your body repair and rebuild so you’re fresh again the next day.
Some important factors that may be a part of this routine could be getting daily sun exposure particularly earlier in the day, avoiding caffeine and alcohol too late in the day, and keeping your bedroom dark and cool at night. Meditation or breathing drills may also be helpful in decreasing anxiety and insomnia before you go to bed and help you fall asleep faster. Some teas and supplements may also be beneficial to help you relax and get better sleep but keep an eye on consuming too much liquid before bed so you aren’t waking up to use the bathroom at night and disrupting your sleep cycle. In general it is best to avoid sleeping pills as while they may help you fall asleep faster, they typically decrease the quality of sleep you get which means less of all the important rebuilding and memory consolidating effects of sleep.
Sleep Action Strategies:
Minimum Dose: Go to bed and wake up at the same time every day (7-9 hours)
- Getting at least 7-9 hours of sleep per night will ensure your body has enough time to adequately repair tissues and maintain healthy immune function. Ideally your sleep and wake times should stay consistent throughout the week so your body can properly regulate its circadian rhythm. This will also help you fall asleep faster due to your body being able to predict when to “shut off” each day. If you are trying to shift your sleep schedule it is best to try and do it a little at a time, changing your schedule no more than 30 minutes per night if possible until you reach your desired time.
Moderate Dose: Eliminate electronic use for 1 hour pre-bed and ensure cool/dark bedroom, consistent sleep schedule
- To further enhance your sleep quality, keeping your sleep environment dark and cool and free of electronics will help your body prepare for bed. Electronic screens contain a lot of blue light which can depress your body’s secretion of melatonin, an important hormone that aids in falling asleep and keeping your circadian rhythm. By looking at these screens late at night it can also cause your body to be in a more alert state making it harder to fall asleep. Aside from eliminating excess light from your bedroom you also want to maintain a cool temperature to aid in sleep. Temperature is also a factor in falling asleep faster and regulating wake up time – in general a cooler room is better though the exact temperature will vary from person to person so you will have to test this out yourself to find what’s comfortable.
High Dose: Develop a nighttime routine, consider supplementation
- Maintaining a consistent routine composed of the things discussed above will greatly benefit your sleep. Additional things you can include in a nighttime routine would be avoiding caffeine/alcohol after 3 pm, performing a light stretching/breathing practice, limiting large meals within 3 hours of bedtime, and taking a relaxing, hot shower before bed. If you are someone whose mind is always going it may also be helpful to do some type of journaling or list making before bed to get your mind off things you have to do the next day. Some supplements or teas may help improve how quickly you fall asleep and/or sleep quality. The only caution with teas is that you are taking in fluids right before bed so if getting up to use the bathroom is an issue for you you may want to use supplements. Some supplements that are beneficial before sleep include melatonin, magnesium, lavender, glycine, theanine, lemon balm, and ashwagandha. Always consult your doctor before taking any herbal supplements to make sure there are no potential drug interactions if you are on any prescription medications.
4. Stress
Excess stress, whether physical or mental is not a good thing, especially during these times. An increased stress response can depress the immune system and contribute to increased rates of depression, anxiety, insomnia, and other mental health disorders. It can also worsen comorbidities such as heart disease and diabetes by disrupting normal blood sugar levels. A classic study published in the New England Journal of Medicine actually looked at stress levels and subsequent risk of infection to a variety of common cold viruses and found up to a 6 times increased risk of infection in those under the most stress.
A certain amount of stress is healthy and allows the body to grow stronger and more resilient if given adequate time to adapt. Unfortunately in this prolonged pandemic period the stress becomes chronic and has negative consequences on overall health. While stress can come from physical activity most people do not train anywhere near the level it takes to break the body down this way outside of elite athletes or very physically demanding jobs. Most stress is going to be coming from fear, anxiety, depression, and other means especially with all the lockdown measures and feelings of social isolation present during this time.
A large body of research has looked at various breathing and meditation techniques and how they help decrease feelings of stress as well as reduce cardiovascular risk factors such as high blood pressure, heart rate, blood lipids, and markers of oxidative stress. Breathing drills can be done for as little as 5 minutes per day and show benefits to overall mood and blood markers of health. A number of supplements and nutrients can also have a profound effect on stress and how the body can cope with it. There is a class of supplements called “adaptogens” that provide broad spectrum benefits in both subjective and objective markers of stress when supplemented at appropriate dosages. You may also find benefit from getting outdoors into nature and simply taking a walk. Significant research done in Japan has looked at the benefits of “forest bathing” and they actually will write prescriptions to people to take the time and get outside. Just walking or viewing the outdoors in a forest or park can reduce stress levels, decrease blood pressure, and improve your mood and well-being.
Stress Action Strategies:
Minimum Dose: Take 5 minutes before bed to focus on your breathing/meditation
- To prepare for bed and wind down at night try to do 5 minutes of breathing or a meditation practice to shift your body into a more relaxed state and let go of the stress of the day. This can be done either sitting or lying down on your back with the knees bent, place one hand on your chest and one on your stomach and try to feel both areas rise and fall together. Breathe in through the nose and out through the mouth at a pace of 4 seconds on the inhale and 4 or more when exhaling.
Moderate Dose: Perform 2-3 weekly breathing/meditation/yoga sessions, spend time outdoors
- If you would like to reduce your stress levels and benefit your cardiovascular health and immunity even more adding in some longer sessions a few times a week is recommended. This could continue to be a breathing or meditation practice or you could begin to participate in yoga, tai-chi or another similar activity introducing some movement alongside the breathing techniques. Ideally these could also be done outdoors if the weather is nice to provide further stress reduction benefits via the effects of sunlight and forest bathing. Getting 30 minutes of sun exposure daily is also good for regulating your body’s circadian rhythm and improving sleep.
High Dose: Perform a daily breathing/stretching routine (possibly outside) and use targeted supplementation to reduce stress
- To keep yourself feeling great and minimizing any excessive stress some kind of daily movement/meditation practice would be recommended – this could be as little as 10-15 minutes, preferably outdoors. You will find significant benefits to your blood pressure and heart rate as well as enjoying an improved mood and overall sense of happiness. Supplementation can also help combat the effects of all the stressors in the modern world. There is a broad class of compounds known as adaptogens that provide wide-spectrum benefits throughout the body in dealing with the effects of stress. Some of the more proven supplements in this category include ashwagandha and rhodiola rosea. Other supplements that may help reduce stress and anxiety include theanine, gotu kola, kava, lavender, and inositol. Always consult your doctor before taking any herbal supplements to make sure there are no potential drug interactions if you are on any prescription medications.
References
- Zhou, Yue, et al. “Obesity and diabetes as high‐risk factors for severe coronavirus disease 2019 (Covid‐19).” Diabetes/Metabolism Research and Reviews (2020): e3377.
- Castillo, Marta Entrenas, et al. “Effect of calcifediol treatment and best available therapy versus best available therapy on intensive care unit admission and mortality among patients hospitalized for COVID-19: A pilot randomized clinical study.” The Journal of steroid biochemistry and molecular biology 203 (2020): 105751.
- Alexander, Jan, et al. “Early nutritional interventions with zinc, selenium and vitamin D for raising anti-viral resistance against progressive COVID-19.” Nutrients 12.8 (2020): 2358.
- Zhang, Jinsong, et al. “Association between regional selenium status and reported outcome of COVID-19 cases in China.” The American Journal of Clinical Nutrition 111.6 (2020): 1297-1299.
- Cohen, Sheldon, David AJ Tyrrell, and Andrew P. Smith. “Psychological stress and susceptibility to the common cold.” New England journal of medicine 325.9 (1991): 606-612.
- Yan, Zhen, and Hannah R. Spaulding. “Extracellular superoxide dismutase, a molecular transducer of health benefits of exercise.” Redox biology (2020): 101508.
- Hu, Xingzhong, et al. “Low Serum Cholesterol Level Among Patients with COVID-19 Infection in Wenzhou, China.” China (February 21, 2020) (2020).
- Hu, Xingzhong, et al. “Declined serum high density lipoprotein cholesterol is associated with the severity of COVID-19 infection.” Clinica Chimica Acta 510 (2020): 105-110.
- Zaki, Nazar, Hany Alashwal, and Sahar Ibrahim. “Association of hypertension, diabetes, stroke, cancer, kidney disease, and high-cholesterol with COVID-19 disease severity and fatality: a systematic review.” Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14.5 (2020): 1133-1142.
- Marcello, Alessandro, et al. “The cholesterol metabolite 27-hydroxycholesterol inhibits SARS-CoV-2 and is markedly decreased in COVID-19 patients.” Redox biology 36 (2020): 101682.
- Moghaddam, Arash, et al. “Selenium deficiency is associated with mortality risk from COVID-19.” Nutrients 12.7 (2020): 2098.
- Panagiotou, Grigorios, et al. “Low serum 25-hydroxyvitamin D (25 [OH] D) levels in patients hospitalised with COVID-19 are associated with greater disease severity: results of a local audit of practice.” medRxiv (2020).
- Maghbooli, Zhila, et al. “Vitamin D sufficiency reduced risk for morbidity and mortality in COVID-19 patients.” Available at SSRN 3616008 (2020).
- Qian, Hua, et al. “Indoor transmission of SARS-CoV-2.” medRxiv (2020).
- Tartof, Sara Y., et al. “Obesity and mortality among patients diagnosed with COVID-19: results from an integrated health care organization.” Annals of internal medicine (2020).
- Zhu, Lihua, et al. “Association of blood glucose control and outcomes in patients with COVID-19 and pre-existing type 2 diabetes.” Cell metabolism (2020).
- Lippi, Giuseppe, Johnny Wong, and Brandon Michael Henry. “Hypertension and its severity or mortality in Coronavirus Disease 2019 (COVID-19): a pooled analysis.” Pol Arch Intern Med 130.4 (2020): 304-309.
- Meng, Juan, et al. “Renin-angiotensin system inhibitors improve the clinical outcomes of COVID-19 patients with hypertension.” Emerging microbes & infections 9.1 (2020): 757-760.
- Le Bert, Nina, et al. “SARS-CoV-2-specific T cell immunity in cases of COVID-19 and SARS, and uninfected controls.” Nature 584.7821 (2020): 457-462.
- Sette, Alessandro, and Shane Crotty. “Pre-existing immunity to SARS-CoV-2: the knowns and unknowns.” Nature Reviews Immunology 20.8 (2020): 457-458.
- Hammock, Bruce D. “The Overlooked Storm in Coronavirus Disease 2019 (COVID-19)?.” Eicosanoids 3 (2020): Q1.
- Bousquet, Jean, et al. “Cabbage and fermented vegetables: from death rate heterogeneity in countries to candidates for mitigation strategies of severe COVID‐19.” Allergy (2020).
- Jiménez-Pavón, David, Ana Carbonell-Baeza, and Carl J. Lavie. “Physical exercise as therapy to fight against the mental and physical consequences of COVID-19 quarantine: Special focus in older people.” Progress in cardiovascular diseases (2020).
- O’rourke, R. W., et al. “Hypoxia-induced inflammatory cytokine secretion in human adipose tissue stromovascular cells.” Diabetologia 54.6 (2011): 1480-1490.
- Polonikov, Alexey. “Endogenous Deficiency of Glutathione as the Most Likely Cause of Serious Manifestations and Death in COVID-19 Patients.” ACS Infectious Diseases (2020).
- Aquilani, Roberto, et al. “Effects of oral amino acid supplementation on long-term-care-acquired infections in elderly patients.” Archives of gerontology and geriatrics 52.3 (2011): e123-e128.
- van der Gaag, Ellen, et al. “Influence of dietary advice including green vegetables, beef, and whole dairy products on recurrent upper respiratory tract infections in children: A randomized controlled trial.” Nutrients 12.1 (2020): 272.
- Zhang, Ying, et al. “Effects of N-acetylcysteine treatment in acute respiratory distress syndrome: a meta-analysis.” Experimental and Therapeutic Medicine 14.4 (2017): 2863-2868.
- Schuch, Felipe B., et al. “Associations of moderate to vigorous physical activity and sedentary behavior with depressive and anxiety symptoms in self-isolating people during the COVID-19 pandemic: A cross-sectional survey in Brazil.” Psychiatry research 292 (2020): 113339.
- Tanaka, S-I., et al. “Impaired immunity in obesity: suppressed but reversible lymphocyte responsiveness.” International journal of obesity and related metabolic disorders: journal of the International Association for the Study of Obesity 17.11 (1993): 631-636.
- Andersen, Catherine J., Kelsey E. Murphy, and Maria Luz Fernandez. “Impact of obesity and metabolic syndrome on immunity.” Advances in Nutrition 7.1 (2016): 66-75.
- Sattar, Naveed, Iain B. McInnes, and John JV McMurray. “Obesity a risk factor for severe COVID-19 infection: multiple potential mechanisms.” Circulation (2020).
- Luzi, Livio, and Maria Grazia Radaelli. “Influenza and obesity: its odd relationship and the lessons for COVID-19 pandemic.” Acta Diabetologica (2020): 1-6.
- Helgadóttir, Björg, et al. “Training fast or slow? Exercise for depression: a randomized controlled trial.” Preventive medicine 91 (2016): 123-131.
- Kvam, Siri, et al. “Exercise as a treatment for depression: a meta-analysis.” Journal of affective disorders 202 (2016): 67-86.
- Harvey, Samuel B., et al. “Exercise and the prevention of depression: results of the HUNT cohort study.” American Journal of Psychiatry 175.1 (2018): 28-36.
- Paolucci, Emily M., et al. “Exercise reduces depression and inflammation but intensity matters.” Biological psychology 133 (2018): 79-84.
- Pinto, Ana Jéssica, et al. “Combating physical inactivity during the COVID-19 pandemic.” Nature Reviews Rheumatology (2020): 1-2.
- Damiot, Anthony, et al. “Immunological implications of physical inactivity among older adults during the covid-19 pandemic.” Gerontology 66.5 (2020): 431-438.
- Xiang, Mi, Zhiruo Zhang, and Keisuke Kuwahara. “Impact of COVID-19 pandemic on children and adolescents’ lifestyle behavior larger than expected.” Progress in Cardiovascular Diseases (2020).
- Sheridan, Patricia A., et al. “Obesity is associated with impaired immune response to influenza vaccination in humans.” International journal of obesity 36.8 (2012): 1072-1077.
- Painter, Scott D., Inna G. Ovsyannikova, and Gregory A. Poland. “The weight of obesity on the human immune response to vaccination.” Vaccine 33.36 (2015): 4422-4429.
- Green, William D., and Melinda A. Beck. “Obesity impairs the adaptive immune response to influenza virus.” Annals of the American Thoracic Society 14.Supplement 5 (2017): S406-S409.
- Hagan, Thomas, et al. “Antibiotics-driven gut microbiome perturbation alters immunity to vaccines in humans.” Cell 178.6 (2019): 1313-1328.
- Ono, Ben Hur Vitor Silva, and José Carlos Souza. “Sleep and immunity in times of COVID-19.” Revista da Associação Médica Brasileira 66 (2020): 143-147.
- Brown, R., et al. “Suppression of immunity to influenza virus infection in the respiratory tract following sleep disturbance.” Regional immunology 2.5 (1989): 321-325.
- Motivala, Sarosh J., and Michael R. Irwin. “Sleep and immunity: cytokine pathways linking sleep and health outcomes.” Current Directions in Psychological Science 16.1 (2007): 21-25.
- Irwin, Michael. “Effects of sleep and sleep loss on immunity and cytokines.” Brain, behavior, and immunity 16.5 (2002): 503-512.
- de Almeida, Carlos Mauricio Oliveira, and Adriana Malheiro. “Sleep, immunity and shift workers: a review.” Sleep science 9.3 (2016): 164-168.
- Spiegel, Karine, John F. Sheridan, and Eve Van Cauter. “Effect of sleep deprivation on response to immunization.” Jama 288.12 (2002): 1471-1472.
- Polesel, Daniel Ninello, et al. “Lack of sleep can jeopardize vaccine effectiveness.” American journal of infection control 45.1 (2017): 96-97.
- Wood, Thomas R., and Guðmundur F. Jóhannsson. “Metabolic health and lifestyle medicine should be a cornerstone of future pandemic preparedness.” Lifestyle Medicine: e2.
- Kuo, Chia-Ling, et al. “COVID-19 severity is predicted by earlier evidence of accelerated aging.” Medrxiv (2020).
- Weller, Richard B. “Sunlight has cardiovascular benefits independently of vitamin D.” Blood purification 41.1-3 (2016): 130-134.
- Moozhipurath, Rahul Kalippurayil, Lennart Kraft, and Bernd Skiera. “Evidence of Protective Role of Ultraviolet-B (UVB) Radiation in Reducing COVID-19 Deaths.” medRxiv (2020).
- Cooper, Isabella D., et al. “Relationships between hyperinsulinaemia, magnesium, vitamin D, thrombosis and COVID-19: rationale for clinical management.” Open heart 7.2 (2020): e001356.
- McCarty, Mark F., and James J. DiNicolantonio. “Nutraceuticals have potential for boosting the type 1 interferon response to RNA viruses including influenza and coronavirus.” Progress in Cardiovascular Diseases (2020).
- DiNicolantonio, James J., and Jorge Barroso-Aranda. “Harnessing adenosine A2A receptors as a strategy for suppressing the lung inflammation and thrombotic complications of COVID-19: Potential of pentoxifylline and dipyridamole.” (2020): 110051.
- DiNicolantonio, James J., and Mark McCarty. “Thrombotic complications of COVID-19 may reflect an upregulation of endothelial tissue factor expression that is contingent on activation of endosomal NADPH oxidase.” Open Heart 7.1 (2020): e001337.
- DiNicolantonio, James J., and Mark F. McCarty. “Targeting Casein Kinase 2 with Quercetin or Enzymatically Modified Isoquercitrin as a Strategy for Boosting the Type 1 Interferon Response to Viruses and Promoting Cardiovascular Health.” Medical Hypotheses (2020): 109800.
- Tison, Geoffrey H., et al. “Worldwide effect of COVID-19 on physical activity: a descriptive study.” Annals of internal medicine (2020).
- Mattioli, Anna V., et al. “Quarantine during COVID-19 outbreak: Changes in diet and physical activity increase the risk of cardiovascular disease.” Nutrition, Metabolism and Cardiovascular Diseases 30.9 (2020): 1409-1417.
- Martínez-Velilla, Nicolás, et al. “Effect of exercise intervention on functional decline in very elderly patients during acute hospitalization: a randomized clinical trial.” JAMA internal medicine 179.1 (2019): 28-36.
- Ibrahim, Homam, et al. “Therapeutic blockade of inflammation in severe COVID-19 infection with intravenous N-acetylcysteine.” Clinical Immunology 219 (2020): 108544.
- Silvagno, Francesca, Annamaria Vernone, and Gian Piero Pescarmona. “The role of glutathione in protecting against the severe inflammatory response triggered by COVID-19.” Antioxidants 9.7 (2020): 624.
- Jaiswal, N., M. Bhatnagar, and H. Shah. “N-acetycysteine: A potential therapeutic agent in COVID-19 infection.” Medical hypotheses 144 (2020): 110133.
- Guloyan, Vika, et al. “Glutathione Supplementation as an Adjunctive Therapy in COVID-19.” Antioxidants 9.10 (2020): 914.
- Huang, Yeen, and Ning Zhao. “Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: a web-based cross-sectional survey.” Psychiatry research (2020): 112954.
- Marelli, Sara, et al. “Impact of COVID-19 lockdown on sleep quality in university students and administration staff.” Journal of Neurology (2020): 1-8.
- Kempuraj, Duraisamy, et al. “COVID-19, mast cells, cytokine storm, psychological stress, and neuroinflammation.” The Neuroscientist 26.5-6 (2020): 402-414.
- Barzilay, Ran, et al. “Resilience, COVID-19-related stress, anxiety and depression during the pandemic in a large population enriched for healthcare providers.” Translational psychiatry 10.1 (2020): 1-8.
- Salari, Nader, et al. “Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis.” Globalization and health 16.1 (2020): 1-11.
- Schönrich, Günther, Martin J. Raftery, and Yvonne Samstag. “Devilishly radical NETwork in COVID-19: Oxidative stress, neutrophil extracellular traps (NETs), and T cell suppression.” Advances in Biological Regulation 77 (2020): 100741.
- Goyal, Madhav, et al. “Meditation programs for psychological stress and well-being: a systematic review and meta-analysis.” JAMA internal medicine 174.3 (2014): 357-368.
- Pace, Thaddeus WW, et al. “Effect of compassion meditation on neuroendocrine, innate immune and behavioral responses to psychosocial stress.” Psychoneuroendocrinology 34.1 (2009): 87-98.
- Astin, John A. “Stress reduction through mindfulness meditation.” Psychotherapy and psychosomatics 66.2 (1997): 97-106.
- Altman, Kamara Elaine R. “A brief therapy model to reduce stress by practicing breathing exercises, mindful meditation, and yoga stretching.” (2002): 0530-0530.
- Mourya, Monika, et al. “Effect of slow-and fast-breathing exercises on autonomic functions in patients with essential hypertension.” The journal of alternative and complementary medicine 15.7 (2009): 711-717.
- Naik, G. Sunil, G. S. Gaur, and G. K. Pal. “Effect of modified slow breathing exercise on perceived stress and basal cardiovascular parameters.” International journal of yoga 11.1 (2018): 53.
- Martarelli, Daniele, et al. “Diaphragmatic breathing reduces exercise-induced oxidative stress.” Evidence-Based Complementary and Alternative Medicine 2011 (2011).
- Mao, Gen-Xiang, et al. “Therapeutic effect of forest bathing on human hypertension in the elderly.” Journal of cardiology 60.6 (2012): 495-502.
- Hansen, Margaret M., Reo Jones, and Kirsten Tocchini. “Shinrin-yoku (forest bathing) and nature therapy: A state-of-the-art review.” International journal of environmental research and public health 14.8 (2017): 851.
- Jafar, Nagham, Hawa Edriss, and Kenneth Nugent. “The effect of short-term hyperglycemia on the innate immune system.” The American journal of the medical sciences 351.2 (2016): 201-211.
- Brawner, Clinton A., et al. “Maximal Exercise Capacity is Inversely Related to Hospitalization Secondary to Coronavirus Disease 2019.” Mayo Clinic Proceedings. Elsevier, 2020.