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Switch up your interval runs for this EMOM (every minute on the minute) workout led by pro marathon runner Stephen Scullion.
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See how hard you can push yourself in 7 minutes during this quick AMRAP with Under Armour trainer Marquan Jones.
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Try this balance and core workout from gold medalist Lindsey Vonn.
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Recent scientific papers have highlighted the role vitamin D may be playing in the COVID-19 pandemic, especially in severe cases. Considering researchers have also shown that SARS-CoV-2 is rapidly inactivated by sunlight,1 areas that are banning people from parks and beaches, are undoubtedly committing a grave error.
Stay-at-home recommendations in general may also have been a bad idea overall. Indeed, New York Gov. Andrew Cuomo stated,2 May 6, 2020, that 66% of new hospital admissions for COVID-19 were individuals who had been sequestering at home.
A majority of those cases were also minorities such as African-Americans, who are far more prone to vitamin D deficiency due to their darker skin.3 When Cuomo first heard about it, he said he immediately thought maybe people had been going out in spite of the shelter-in-place order, and maybe taking public transportation.4
In actuality they were all at home where they were supposed to be. Interestingly, Dr. David Katz, president of True Health Initiative and founding director of the Yale-Griffin Prevention Research Center, predicted5,6 this would happen.
Chinese researchers have also noted that a majority of outbreaks in the 320 municipalities reviewed were the result of indoor spread of the disease, with the home accounting for 79.9% of cases, followed by transportation at 34%.
According to the authors,7 "All identified outbreaks of three or more cases occurred in an indoor environment, which confirms that sharing indoor space is a major SARS-CoV-2 infection risk." As noted in a May 11, 2020, American Thinker article:8
"Very likely, you already instinctively know that the guidelines suggesting that it's somehow helpful to keep a six-foot space between healthy people, even outdoors, is not based on science, but just an arbitrary suggestion we've been conditioned to accept without evidence.
And your gut feeling would be right. There's a reason that "social distancing 'wasn't a buzzword common to the American lexicon prior to 2020. There's very little science behind "social distancing' at all.
'It turns out,' Julie Kelly writes9 at American Greatness, 'as I wrote10 last month, 'social distancing' is untested pseudoscience particularly as it relates to halting the transmission of the SARS-CoV-2 virus. On its website, the CDC provides no links to any peer-reviewed social distancing studies that bolster its official guidance.' There's a reason for the lack of peer-reviewed studies on the CDC website. She continues:
'The alarming reality is that social distancing never has been tested on a massive scale in the modern age; its current formula was conceived during George W. Bush's administration and met with much-deserved skepticism.
'People could not believe that the strategy would be effective or even feasible,' one scientist told11 the New York Times last month. A high school science project12 — no, I am not joking — added more weight to the concept.
'Social distancing' is very much a newfangled experiment, not settled science. And, Kelley writes, the results are suggesting that our 'Great Social Distancing Experiment of 2020' will be 'near the top of the list' of 'bad experiments gone horribly wrong.'"
In the video above, published May 11, 2020, on Medscape.com, Dr. JoAnn E. Manson, professor of medicine and chief of the division of preventive medicine at Harvard Medical School, discusses the protective role of vitamin D against COVID-19.
Manson points out that growing evidence suggests your vitamin D status may in fact play an important role in your risk of developing COVID-19, as well as the severity of the illness. It's well-known that vitamin D is important for innate immunity and that it boosts your immune function against viral diseases.
Importantly, as noted by Manson, vitamin D also has "an immune modulating effect and can lower inflammation, and this may be relevant to the respiratory response during COVID-19 and the cytokine storm that's been demonstrated."
Manson cites evidence from three South-Asian studies showing people with serious COVID-19 infection are far more likely to have insufficient levels of vitamin D compared to those with mild illness. Vitamin D deficient patients had, on average, an eightfold higher risk of serious COVID-19 illness compared to those with sufficient levels.
Harvard Medical School is starting a study to investigate whether vitamin D supplementation lowers the risk of COVID-19 specifically, and/or improves clinical outcomes, but in the meantime, Manson urges people to spend more time outdoors to improve their vitamin D levels through sun exposure, and to optimize their vitamin D levels through food and supplements.
Manson is far from alone in her recommendations. Irish researchers recently published an editorial13 highlighting the role of vitamin D deficiency in severe COVID-19 infections. According to the authors:14
"… the evidence supporting a protective effect of vitamin D against severe COVID‐19 disease is very suggestive, a substantial proportion of the population in the Northern Hemisphere will currently be vitamin D deficient, and supplements, for example, 1,000 international units (25 micrograms) per day are very safe.
It is time for governments to strengthen recommendations for vitamin D intake and supplementation, particularly when under lock‐down."
A May 6, 2020, report15 in the journal Nutrients points out that vitamin D concentrations are lower in patients with positive PCR (polymerase chain reaction) tests for SARS-CoV-2. As noted in this report, which retrospectively investigated the vitamin D levels obtained from a cohort of patients in Switzerland:16
"In this cohort, significantly lower 25(OH)D levels were found in PCR-positive for SARS-CoV-2 (median value 11.1 ng/mL) patients compared with negative patients (24.6 ng/mL); this was also confirmed by stratifying patients according to age >70 years. On the basis of this preliminary observation, vitamin D supplementation might be a useful measure to reduce the risk of infection."
Another May 6, 2020, report,17 published in Aging Clinical and Experimental Research (its prepublication featured in the Daily Mail May 118), found that countries with lower vitamin D levels also have higher mortality rates from COVID-19. According to the authors:19
"The Seneca study showed a mean serum vitamin D level of 26 nmol/L in Spain, 28 nmol/L in Italy and 45 nmol/L in the Nordic countries, in older people. In Switzerland, mean vitamin D level is 23 nmol/L in nursing homes and in Italy 76% of women over 70 years of age have been found to have circulating levels below 30 nmol/L.
These are the countries with high number of cases of COVID-19 and the aging people is the group with the highest risk for morbidity and mortality with SARS-CoV2."
In the preprint version20 of this paper, the authors concluded: "We believe that we can advise vitamin D supplementation to protect against SARS-CoV2 infection." In the final version,21 they toned down the recommendation to: "We hypothesize that vitamin D may play a protective role for COVID-19."
Data22 from a clinical trial by GrassrootsHealth — an organization that we have supported for over 13 years — also reveals a link between vitamin D status and COVID-19 severity.
Mark Alipio — who received no funding for his work — released data from an analysis of 212 people with lab-confirmed COVID-19 and for whom serum 25(OH)D levels were available. Using a classification of symptoms based on previous research, he employed statistical analysis to compare the differences in clinical outcomes against the levels of vitamin D.
Of the 212 people, 49 had mild disease; 59 had ordinary disease; 56 were severe and 48 were critical. In the initial study group of 212 patients (see Table 1 below), 55 had normal vitamin D levels, which Alipio defined as greater than 30 ng/ml; 80 had insufficient levels of 21 to 29 ng/ml and 77 had deficient levels of less than 20 ng/ml.
Vitamin D levels were strongly correlated to the severity of the illness experienced. It is important to note that most experts consider 30 ng/ml half of what an optimum vitamin D level should be, which is 60 to 80 ng/ml.
Of the 49 with mild illness, 47 had normal vitamin D levels. For those of you who are not good with math that means that 96% of the patients with mild illness had "normal" levels of vitamin D. Note again this "normal" level was above 30 ng/mL, and most experts would raise that to 60 ng/mL.
Of the 104 with severe or critical illness, only four had normal levels of vitamin D. That is 4% or the reciprocal of the mild group. How much stronger a correlation could one hope for? Alipio concluded:23
"… this study provides substantial information to clinicians and health policy-makers. Vitamin D supplementation could possibly improve clinical outcomes of patients infected with Covid-2019 based on increasing odds ratio of having a mild outcome when serum (OH)D level increases."
Indeed, there is strong scientific evidence vitamin D plays a central role in your immune response and your ability to fight infections in general, so there's little reason to think it wouldn't provide similar protection against COVID-19.
In this video, Ivor Cummins, biochemist and chief program officer for Irish Heart Disease Awareness, explains how higher levels of vitamin D may reduce your risk of negative outcomes from COVID-19.
He also reviews some of the conditions associated with low vitamin D levels, such as insulin resistance and high levels of inflammation. As discussed in "The Real Pandemic Is Insulin Resistance," obesity, high blood pressure, diabetes and heart disease are comorbidities for severe COVID-19, and insulin resistance is the underlying problem in all of these.
As noted in "Vitamin D and the Antiviral State," a literature review article published in the Journal of Clinical Virology in 2011:24
"Interventional and observational epidemiological studies provide evidence that vitamin D deficiency may confer increased risk of influenza and respiratory tract infection. Vitamin D deficiency is also prevalent among patients with HIV infection.
Cell culture experiments support the thesis that vitamin D has direct anti-viral effects particularly against enveloped viruses. Though vitamin D's anti-viral mechanism has not been fully established, it may be linked to vitamin D's ability to up-regulate the anti-microbial peptides LL-37 and human beta defensin 2."
SARS-CoV-2 is an enveloped type of virus,25 which means vitamin D may actually have a direct antiviral effect on it. Future studies will have to confirm that, but in the meantime, there's absolutely no reason to ignore your vitamin D level. As reported in a recent GrassrootsHealth press release:26
"Vitamin D has several mechanisms that can reduce risk of infections. Important mechanisms regarding respiratory tract infections include:
Vitamin D deficiency has been found to contribute to acute respiratory distress syndrome, a major cause of death associated with COVID-19 … To reduce risk of infection, it is recommended that people at risk of influenza and/or COVID-19 consider taking 10,000 IU/day (250 micrograms/day) of vitamin D for a few weeks to rapidly raise 25-hydroxyvitamin D [25(OH)D] concentrations, followed by at least 5000 IU/day.
The goal should be to raise 25(OH)D concentrations above 40-60 ng/ml (100-150 nmol/l), taking whatever is necessary for that individual to achieve and maintain that level. For treatment of people who become infected with COVID-19, higher vitamin D doses would be required to rapidly increase 25(OH)D concentrations."
As the world’s attention remains focused on the COVID-19 pandemic, essential attention is turned away from other life-threatening epidemics, including opioid addiction. Prior to the COVID-19 crisis, opioid misuse and addiction had become rampant in the U.S. In the late 1990s, drug companies assured doctors that opioid pain relievers were safe and nonaddictive, leading to an increase in prescribing rates.
Opioid overdose rates increased rapidly as it became clear that opioids can be highly addictive. In 2018, 46,802 Americans died from an opioid overdose while 1.7 million suffered from substance use disorders related to opioid pain relievers.
The economic burden of prescription opioid misuse alone is $78.5 billion in the U.S. annually, which includes not only health care costs but also lost productivity, addiction treatment and criminal justice involvement.1 The economic toll, and the death toll, from the opioid epidemic is, sadly, set to rise even further now that it has collided with the COVID-19 pandemic.
There are physical and psychological reasons why COVID-19 poses a significant challenge for people with opioid use disorder (OUD), which affects at least 2 million Americans, and those who misuse opioids — another 10 million.2 Worldwide, 40.5 million people struggle with opioid dependence, a global prevalence of 510 cases per 100,000 people.3
Chronic respiratory disease increases the risk for fatal overdose in people who use opioids, and COVID-19 leads to compromised lung function.
Further, opioid misuse can lead to slowed breathing and hypoxemia, which can cause cardiac, pulmonary and brain complications, as well as overdose and death. As such, according to an article in the Annals of Internal Medicine, “these individuals may be at increased risk for the most adverse consequences of COVID-19.”4
People who are addicted to opioids may also be more likely to suffer from conditions that make them more vulnerable to COVID-19, including being a smoker who suffers from lung or heart disease, being homeless or having experienced other health effects from drug addiction.5 Threat of infection aside, there are a number of indirect ways that people with OUD may be adversely affected by COVID-19 as well.
“Before the first COVID-19 case in the United States, a different epidemic — the opioid crisis — was taking the lives of 130 Americans per day,” wrote two doctors from Yale School of Medicine in Annals of Internal Medicine.
“Given that infection epidemics disproportionately affect socially marginalized persons with medical and psychiatric comorbid conditions — characteristics of those with opioid use disorder (OUD) — we are gravely concerned that COVID-19 will increase already catastrophic opioid overdose rates.”6 Some of the challenges faced by people with OUD during the COVID-19 pandemic include:7
Disruptions of care during the COVID-19 pandemic are a major concern for people with opioid use disorder, who depend on regular face-to-face health care. Many rehab facilities have closed, limited programs or limited new admissions over fears of COVID-19 spreading in a communal living facility.8
Access to medications for addiction treatment may be restricted, while patients may also face simultaneous challenges like loss of work, housing and food security, which could trigger a downward spiral leading to relapse and delayed recovery.
"The COVID-19 pandemic strikes at a moment when our national response to the opioid crisis was beginning to coalesce, with more persons gaining access to treatment and more patients receiving effective medications. COVID-19 threatens to dramatically overshadow and reverse this progress," according to researchers with the Johns Hopkins School of Medicine.9
The social isolation imposed by the pandemic is also highly problematic and, by increasing stress and anxiety, could heighten substance abuse, opioid usage and overdose.
In addition to limiting access to peer-support groups and other vital sources of social connection for recovering addicts, “Persons who are isolated and stressed — as much of the population is during a pandemic — frequently turn to substances to alleviate their negative feelings,” wrote Dr. Nora Volkow with the National Institute on Drug Abuse. “Those in recovery will face stresses and heightened urges to use substances and will be at greatly increased risk for relapse.”10
There’s also the issue of social isolation indirectly contributing to overdose deaths because no one is there to administer naloxone, an overdose-reversing drug. Volkow continued:11
“Social distancing will increase the likelihood of opioid overdoses happening when there are no observers who can administer naloxone to reverse them and thus when they are more likely to result in fatalities.
Emergency department physicians with increased caseloads may be less likely to initiate buprenorphine therapy for patients with OUD, which is an important component of mitigating the effects of the opioid crisis.”
There are even reports of stigma and discrimination, according to Dr. Peter Grinspoon, who recovered from opioid addiction and teaches medicine at Harvard Medical School. “There are reports surfacing of police departments across the country that are refusing to offer naloxone to patients who have overdosed, on the pretext that it is too dangerous because the ‘addict’ might wake up coughing and sneezing coronavirus droplets.”12
The U.S. unemployment rate may skyrocket to 32.1% in the second quarter of 2020, according to the Federal Reserve Bank of St. Louis.13 Previously, the highest rate of unemployment in U.S. history was 24.9%, which occurred in 1933 during the Great Depression.14 The massive job losses may singlehandedly increase opioid overdose deaths, as a strong connection has been revealed between the two in the past.
A 2019 study in the Medical Care Research Review journal looked at the effects of state-level economic conditions — unemployment rates, median house prices, median household income, insurance coverage and average hours of weekly work — on drug overdose deaths between 1999 and 2014.15 According to the authors:
"Drug overdose deaths significantly declined with higher house prices … by nearly 0.17 deaths per 100,000 (~4%) with a $10,000 increase in median house price. House price effects were more pronounced and only significant among males, non-Hispanic Whites, and individuals younger 45 years.
Other economic indicators had insignificant effects. Our findings suggest that economic downturns that substantially reduce house prices such as the Great Recession can increase opioid-related deaths, suggesting that efforts to control access to such drugs should especially intensify during these periods."
An earlier investigation, published in the International Journal of Drug Policy in 2017, also connected economic recessions and unemployment with rises in illegal drug use among adults. Twenty-eight studies published between 1990 and 2015 were included in the review, 17 of which found that the psychological distress associated with economic recessions and unemployment was a significant factor. According to the authors:16
"The current evidence is in line with the hypothesis that drug use increases in times of recession because unemployment increases psychological distress which increases drug use. During times of recession, psychological support for those who lost their job and are vulnerable to drug use (relapse) is likely to be important."
In a report by the Well Being Trust (WBT) and the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, it’s estimated that up to 75,000 people may die during the COVID-19 pandemic from drug or alcohol misuse and suicide. These “deaths of despair” are expected to be exacerbated by three factors already at play:17
In order to come up with their 75,000 figure, the study used data on deaths of despair from 2018 as a baseline, projected levels of unemployment from 2020 to 2029 and then used economic modeling to estimate the additional number of deaths annually. Nine different scenarios were tested, ranging from quick recovery to slow recovery.
In the best-case scenario, 27,644 deaths of despair were estimated while in the worst-case example, 154,037 deaths could occur. While 75,000 was deemed to be “most likely,” the researchers noted, “When considering the negative impact of isolation and uncertainty, a higher estimate may be more accurate.”18
“Undeniably policymakers must place a large focus on mitigating the effects of COVID. However, if the country continues to ignore the collateral damage — specifically our nation’s mental health — we will not come out of this stronger,” Benjamin F. Miller, PsyD, chief strategy officer of WBT, said in a news release.19
A commentary by Dr. Jeffrey A. Lieberman, a psychiatrist with Columbia University’s department of psychiatry, similarly suggested a mental health crisis is looming.20 “The sobering reality is that high-quality mental health care is not available to most people,” Lieberman wrote. “This lack of strategy and access is especially concerning amid disasters such as COVID-19, which can cause considerable psychological trauma.”
As mentioned, prolonged isolation only exacerbates the issue. “The stressors from the pandemic are very, very real and how we cope with these stressors varies enormously,” Volkow told ABC News. “Social isolation is one of the factors that leads [people with substance abuse disorder] … to take drugs, and social isolation leads them to relapse, and the social isolation leads them to continue taking them.”21
With weeks of extended isolation already logged for most Americans, some communities are already reporting a rise in drug overdose deaths. Jacksonville, Florida, for instance, had a 20% increase in overdose emergency calls in March 2020.
Four counties in New York State also reported a rise in overdoses, while Columbus, Ohio, had a surge in overdose deaths, including 12 over a 24-hour period the first week of April.22
Whether overdose deaths are increasing across the U.S. is unknown, as Volkow noted that with COVID-19 shutdowns, collecting reliable data is difficult. However, a spokesperson for the U.S. Centers for Disease Control and Prevention told ABC News that officials are “aware of the concerns involving COVID-19 and drug overdoses and that it could affect some populations with substance use disorders.”23
Experts are recommending increased resources for people struggling with drug addiction, including access to online meetings. Remember that even if you’re socially isolated at home, you can reach out to friends and loved ones via phone or online. Connecting with others, even virtually, can help you to feel less alone. It’s also a good idea to set a limit on watching the news or browsing social media, especially if it increases anxious feelings.24
Like most people, you probably do not enjoy going to the doctor only to be referred to a specialist in a different practice. Unfortunately, fragmented care is often the reality among people suffering from common mental illnesses such as depression or anxiety. Wouldn’t it be nice to have both your behavioral and physical health needs addressed at the same time and in the same place?
In medicine, illnesses of the brain are often treated in specialized settings, separate from the rest of medical care. However, we know that there is a strong link between mental illnesses and numerous medical conditions including heart diseases, lung diseases, immune function, and pain. Mental illnesses can cause or exacerbate physical illnesses, but the reverse is true as well: physical illnesses can result in psychological distress or illness through common pathways such as inflammation. Treating mental illnesses in the primary care setting improves access to mental health care and reduces stigma. Although the burden of mental illnesses in primary care settings is high, many primary care physicians do not feel comfortable managing these conditions alone.
Collaborative care is a team-based model of integrated psychiatric and primary care that can treat mental illnesses in the primary care setting. In our practice, a multidisciplinary “teamlet” of a behavioral health coach, a social worker, and a psychiatrist work together in a coordinated fashion to provide treatment to the patient, and to provide recommendations for the patient’s primary care physician. Treatment is truly patient-centered, and the clinicians often use motivational interviewing to help a patient identify and achieve their behavioral health goals. This model of care is time-limited, generally six sessions every other week for 12 weeks, followed by three monthly maintenance sessions.
Patients may enroll in collaborative care to receive treatment for anxiety or depression, to receive treatment for substance use disorders, or to learn skills to manage stress at work or at home. Goals may include increasing physical activity, setting a quit date for smoking, or practicing mindfulness to reduce anxiety. In addition to behavioral health coaching, the teamlet may also connect a patient to resources (financial, support groups, housing) or provide medication recommendations. To ensure that the patient improves during treatment, collaborative care uses patient-reported outcome measures to drive clinical decision-making, such as symptom rating scales.
The psychological toll of the pandemic on people infected with the virus and their loved ones is profound. The collaborative care team at our institution has adapted to this surge of distress by providing additional support to patients and their families. Through virtual coaching (by phone or video), coaches have broadened their repertoire to provide specific cognitive behavioral therapy (CBT) interventions to address COVID-19 related anxiety and mood symptoms. Patients have access to COVID-19 workbooks, and they may enroll in internet-based CBT modules that focus on managing anxiety or depressive symptoms related to the pandemic.
Whether collaborative care is offered at your doctor’s practice or not, there are many available resources to help you and your loved ones cope during these difficult times. In addition to the resources available at health.harvard.edu, there are the free and evidence-based COVID Coach mobile application, the free online course Coping during the pandemic, and the free online meditation resources for times of social distancing/COVID-19 — all wonderful tools to support your mental health. Lastly, there is a reason why behavioral health coaching often involves physical activity — it remains one of the best ways to rapidly improve your mood, decrease anxiety, and boost your overall brain health.
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