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.

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Combating COVID-19

Modifiable Risk Factors