UPDATED: CORONAVIRUS—What You Can Do To Reduce Your Risk Of Complications

Information about COVID-19 continues to evolve rapidly. In this article, I am adding a brief discussion about cytokine storm, citations, and additional strategies to consider.

Cytokine Storm 

Cytokine storms are a life-threatening complication of COVID-19, one of the ways this infection can turn deadly.

What is a cytokine storm exactly? It is the production of inflammasomes (NRLP3) by our immune cells. In the setting of excessive activation of NFKappaB, production of several pro-inflammation cytokines (IL-1b and IL-18) are dramatically increased. This leads to steadily increasing fluid in the lungs. The patient experiences this as the development of a cough, wheezing, and shortness of breath. Blood oxygenation falls. The patient develops adult respiratory distress syndrome or ARDS. That is typically when they need hospitalization, potentially intensive care support and a ventilator.

Is there anything that we can do to lower our risk of cytokine storm?

There are no clinical trials to answer that question. I can discuss what we know about NRLP3 and NFKappaB and how those are linked to diet and lifestyle choices. There is a more thorough discussion about NRLP3 and NFKappaB in my book, the revised and expanded Wahls Protocol: A Radical New Way to Treat All Chronic Autoimmune Conditions Using Paleo Principles. (See pages 189 and 343 for this discussion ).

Pharmaceutical companies are working hard to develop drugs to reduce the damage caused by out of control NRLP3 and NFKappaB. Many of those very drugs are being tested for COVID-19 treatment. Until we have proven drug treatments, there are diet and lifestyle strategies that I recommend everyone consider to mitigate their risk of illness and inflammation.

There no human trials of dietary approaches, lifestyle, or supplements to reduce risk of cytokine storm, but animal and tissue culture studies do exist that suggest that there are things we can do. It turns out that improving the quality of our diet by consuming more vegetables and berries will reduce the activity of both NFKappaB and NRLP3. The flavonoids quercetin [1] (apples and onions are especially high in quercetin), resveratrol [2] (purples grapes, blueberries, skins of vegetables and berries), curcumin [3] (turmeric spice), and allicin [4] ​(garlic) have been shown to reduce NFKappaB and NRLP3 in animal model and/or human tissue culture studies. Becoming sleep deprived is also associated with increases in NRLP3 and worsening inflammation [5]. Excessive cortisol will also activate NFKappaB [6].

These are uncertain times, with higher levels of anxiety, uncertainty, and stress for many people. Sleep disruption is common. The standard American diet has relatively few vegetables. Whatever progress you can make at improving diet quality, improving sleep, and adding a meditative type practice will help reduce the excessive NFKappaB activation, which could potentially reduce the risk of NRLP3 inflammasomes activating a cytokine storm. Attending as effectively as we can to our self-care is what I recommend to my staff, my family, and my patients to reduce their risk of severe COVID-19.

We all must change how we conduct our daily lives. Persons at greatest risk for severe disease, requiring hospitalization, oxygen, and intensive care support are those:

1. Over the age of 60 
2. With chronic health problems (diabetes, heart disease, severe obesity, lung disease) 
3. With chronic autoimmune condition(s) 
4. Taking immune-suppressing medications 
5. Who smoke 
6. With nutritional depletion (standard westernized diet is likely insufficient in many minerals, including zinc and vitamins C and A)

Young adults are more likely to have mild symptoms and pass the virus to others, leading to a rapid spread of the disease in the community. (But some young people will still experience cytokine storm and end up in the intensive care units). This rapid spread of the virus has created severe strain on healthcare systems across the world. We do not want that severe strain here as well. It is critical that we listen to our local public health officials.

State and local government officials are monitoring the number of new cases diagnosed each day. If community spread is observed, local public health experts will use increasingly severe restrictions to stop the spread and reduce the strain on hospitals.

Many have noticed that it has become difficult to purchase toilet paper because of the increased demand. Store shelves are empty. This is the same thing that is happening in hospitals overwhelmed with COVID-19 patients, where the need for intensive care beds and ventilators exceeds supplies. This is happening in many places around the globe, and it’s why it’s crucial to do everything we can to stop the spread of the virus. I urge you to follow the guidance of your local health experts! We need to protect our hospitals and our communities. We also need to protect ourselves by greatly improving our self-care routine and the quality of our diet.

As always, there are many actions we can control and take immediately that can have a major impact on our health and the health of others. Here are several ways you can improve your resilience and increase the probability of an infection being mild. Remember to work with your personal medical team to reduce your risk of contracting COVID-19.

1. Avoid all non-essential travel and non-essential meetings. 
2. Improve the quality of your diet by removing added sugars, white flours, and processed foods. A high–glycemic index diet dumps a lot of glucose (sugar) into your bloodstream, which decreases your immune cells’ effectiveness at protecting you from illness. Avoid paleo-approved treats, which still have too many high-glycemic ingredients. Focus on vegetables and meat (legumes and gluten-free grains for vegetarians and vegans) and get rid of sweet desserts. [1-4]
3. Get enough sleep, preferably 7 to 9 hours[5]. Sleep is vital to keeping immune cells ready to fight viral infections. Sleep deprivation suppresses your immune system’s innate ability to act as the first line of defense.  
4. Wash your hands with soap and water vigorously for 20 seconds and avoid shaking hands to minimize the spread of the virus. I recently saw a great infographic that said “Wash your hands like you have just chopped hot peppers and are about to put in your contacts.”
5. Wash your nose and sinuses twice a day with a Netipot®. This cleans your nasal tissue and reduces the virus’s ability to take hold. 
6. Monitor your temperature. If it is above 100 degrees F (37.7 Celsius), self-quarantine for 14 days.  
7. Stay home in your room if you become ill. If you develop a cough, sore throat, and runny nose do not go to work or frequent public places, which will spread the disease, perhaps to an at-risk individual for whom an infection could be deadly. Stay in your room and do not infect your family!. 
8. Check your vitamin D level. If your vitamin D level is below 20 ng/ml, you are at increased risk for infection. Even at levels below 40 ng/ml, the risk for a wide variety of poor health outcomes goes up. If your levels are low, work with your personal medical team to increase your vitamin D level to get to the optimal range (top half of the lab’s reference range). Do not overshoot your vitamin D level however as that may become problematic as well. See https://terrywahls.com/shop/ for tests you can order and obtain directly.

Here are some natural remedies I use often in winter to help me and my family avoid and treat illness.

1. 1. Eat raw garlic, which boosts your natural killer immune cells. Daily consumption of raw garlic can help prevent illness and reduce symptoms if you aren’t feeling well. When I develop symptoms, I eat raw garlic four times a day [4]. 

2. Drink fire cider, which is a combination of apple cider vinegar, garlic, peppers, horseradish, and other herbs that amplify the natural killer cells. I take one tablespoon a day to prevent sickness and 1 tablespoon four times a day if I am already feeling ill. 
3. Get more vitamin C. Daily doses of 250 to 500 mg once or twice daily can amplify immune cell activity and strength. We can’t make our own vitamin C. When we become ill, our vitamin C needs to increase. Nutritional biochemist Linus Pauling famously recommended additional vitamin C at the onset of the common cold (another coronavirus) [7].
4. Get more pre-made vitamin A (retinol). I recommend eating liver (6 to 8 ounces) once a week or take organic liver capsules. Liver is an excellent source of the pre-made vitamin A. You can visit https://terrywahls.com/shop/ for the brand of organ meat capsules I suggest to my patients who choose not to eat liver or organ meat. 
5. Get more zinc. Zinc deficiency is very common in those with chronic disease. Adding a zinc lozenge (5 to 50 mg) during the winter may be a wise protective measure for anyone worried about COVID-19 risk.  
6. Consume more fermented foods such as kimchi, sauerkraut, dairy-free yogurt, and kefirs. The probiotics in these foods help modulate the immune response, lowering the risk of septic shock in response to serious viral infections. Sauerkraut is also a good source of vitamin C.
7. Elderberry syrup has been shown to be helpful against the influenza virus[9]. However, elderberry has also been demonstrated to increase the production of some cytokines[10]. For that reason, I do not recommend elderberry for COVID-19 related symptoms. It may increase the risk of cytokine storm and more severe reaction. For that reason, I would NOT use elderberry syrup at this time. 
8. Get more omega-3 fatty acids in your diet or in supplement form. Omega-3 fats are necessary to make resolvins, a signaling molecule that turns off inflammation once the infection is under control or the repair process has been completed [11]. An insufficient omega-3 fatty acid level may contribute to NLRP3 and NFKappaB, driving high levels of cytokine that cannot be modulated correctly by the lungs, leading to cytokine storm and lung damage. Grass-fed meat, wild fish, and fish oil are good sources of omega-3 fatty acids. Hemp, flax, and walnut oil are vegetarian sources.

Here are the links to the CDC and WHO coronavirus sites:

https://www.who.int/health-topics/coronavirus#tab=tab_1

Look for your local public health resources as well. Here is the Iowa coronavirus site.

https://hhs.iowa.gov/

Recent interviews and summits of which I have been part that included a discussion of COVID-19: 

Our Health Talks:

Origins of Health:

https://www.originsofhealth.com/coronavirus-webinar-replay/

Healthy Deviant Podcast:

https://www.facebook.com/livingexperimentpodcast/videos/838247930006863/

My good friend Elisa Song MD is a pediatrician who has written a detailed article about COVID-19 that she is also periodically updating. If you want a more thorough analysis of the risk and discussion of what you can do to protect yourself and your family, read her article:

https://healthykidshappykids.com/2020/02/27/coronavirus-covid-19/

REFERENCES

1. Quercetin Inhibits the Production of IL-1β-Induced Inflammatory Cytokines and Chemokines in ARPE-19 Cells via the MAPK and NF-κB Signaling Pathways. Int J Mol Sci. 2019 Jun 17;20(12). pii: E2957. doi: 10.3390/ijms20122957.
2. The adaptogenic anti-ageing potential of resveratrol against heat stress-mediated liver injury in aged rats: Role of HSP70 and NF-kB signalling. J Therm Biol. 2019 Jul;83:8-21. doi: 10.1016/j.jtherbio.2019.04.012. Epub 2019 May.
3. NCB-02 (standardized Curcumin preparation) protects dinitrochlorobenzene- induced colitis through down-regulation of NFkappa-B and iNOS.  World J Gastroenterol. 2007 Feb 21;13(7):1103-7.
4. Allicin Improves Lung Injury Induced by Sepsis via Regulation of the Toll-Like Receptor 4 (TLR4)/Myeloid Differentiation Primary Response 88 (MYD88)/Nuclear Factor kappa B (NF-κB) Pathway. Med Sci Monit. 2019 Apr 8;25:2567-2576. doi: 10.12659/MSM.914114.
5. The NLRP3 inflammasome modulates sleep and NREM sleep delta power induced by spontaneous wakefulness, sleep deprivation and lipopolysaccharide.
6. Stress and the psyche-brain-immune network in psychiatric diseases based on psychoneuroendocrineimmunology: a concise review. Brain Behav Immun. 2017 May;62:137-150. doi: 10.1016/j.bbi.2017.01.012. Epub 2017 Jan 19. Ann N Y Acad Sci. 2019 Feb;1437(1):31-42. doi: 10.1111/nyas.13728. Epub 2018 May
7. Vitamin C and Immune Function. Nutrients. 2017 Nov 3;9(11). pii: E1211. doi: 10.3390/nu9111211.
8. Enhanced natural killer cell activation by exopolysaccharides derived from yogurt fermented with Lactobacillus delbrueckii ssp. bulgaricus OLL1073R-1 J Dairy Sci. 2016 Feb;99(2):915-923. doi: 10.3168/jds.2015-10376. Epub 2015 Dec 10.
9. Black elderberry (Sambucus nigra) supplementation effectively treats upper respiratory symptoms: A meta-analysis of randomized, controlled clinical trials. Complement Ther Med. 2019 Feb;42:361-365. doi: 10.1016/j.ctim.2018.12.004. Epub 2018 Dec 18.
10. The effect of herbal remedies on the production of human inflammatory and anti-inflammatory cytokines. Isr Med Assoc J. 2002 Nov;4(11 Suppl):919-22.

Inflammation and its resolution in atherosclerosis: mediators and therapeutic opportunities. Nat Rev Cardiol. 2019 Jul;16(7):389-406. doi: 10.1038/s41569-019-0169-2.

From March 15, 2020:

The two biggest risks right now are the mistaken belief that there is nothing you can do to reduce your risk of infection and fear that if you get the virus, your recovery is out of your control. There is much we can do to reduce the spread of the infection and improve the probability of having a mild case if you are infected.

I want to reassure you that though we do have to take this very seriously, there is a lot each of us can do to help protect ourselves and our family.

It is critical that we listen to our local public health officials.  The coronavirus is placing a severe strain on healthcare systems in Europe. We do not want that severe strain here as well. We all must change how we conduct our daily lives.

Persons at greatest risk for severe disease, requiring hospitalization, oxygen and intensive care support are the following:

1. Over the age of 60, 
2. Chronic health problems (diabetes, heart disease, severe obesity, lung disease) 
3. Chronic autoimmune condition 
4. Taking immune-suppressing medications.

Young adults are more likely to have mild symptoms and pass the virus to others, leading to a rapid spread of the disease in the community.  This rapid spread of the virus has created severe strain for the health care systems across the world.

The state and local government officials are monitoring the number of new cases diagnosed each day. If community spread is observed, the local public health experts will use increasingly severe restrictions to stop the spread. This is to reduce the strain on hospitals.

In other countries the demand for intensive care units and ventilators exceeds supplies.

The hospitals are overwhelmed, leading to severe disruption of the health care systems.

Many have noticed that it has become difficult to purchase toilet paper because of the increased demand.  Store shelves are empty. Now imagine this happening to our hospitals. What happens when the increased demand for intensive care beds and ventilators have exceeded what is available?  This is what is happening in Italy. We do not want to have these types of shortages in our communities. I urge you to follow the guidance of your local health experts! We need to protect our hospitals and our communities.

As always, there are many actions we can control and take immediately that can have a major impact on our health. Here are several that will improve your resilience and increase the probability of an infection being mild. Remember to work with your personal medical team to reduce your risk contracting COVID-19.

1. Avoid all non-essential travel and non-essential meetings. 
2. Improve the quality of your diet by removing added sugars, white flours, and pastas. A high–glycemic index diet dumps a lot of glucose (sugar) into your bloodstream, which decreases your immune cells’ effectiveness at protecting you from illness. Avoid paleo-approved treats, which still have too many high-glycemic ingredients. Focus on vegetables and meat (legumes and gluten-free grains for vegetarians and vegans) and get rid of sweet desserts. 
3. Get enough sleep, preferably 7 to 9 hours. Sleep is vital to keeping immune cells ready to fight viral infections. Sleep deprivation suppresses your immune system’s innate ability to act as the first line of defense.  
4. Wash your hands with soap and water vigorously for 20 seconds and avoid shaking hands to minimize the spread of the virus. I recently saw a great infographic that said “Wash your hands like you have just chopped hot peppers and are about to put in your contacts.”
5. Wash your nose and sinuses twice a day with a Netipot®. This cleans your nasal tissue and reduces the virus’s ability to take hold. 
6. Monitor your temperature. If it is above 100 degrees F. (37.7 Celsius) self quarantine for 14 days.  
7. Stay home if you become ill. If you develop a cough, sore throat, and runny nose, do not go to work or frequent public places, which will spread the disease, perhaps to an at-risk individual for whom an infection could be deadly.
8. Check your vitamin D level. If your vitamin D level is below 20 ng/ml, you are at increased risk for infection. Even at levels below 40 ng/ml, the risk for a wide variety of poor health outcomes goes up. If your levels are low, work with your personal medical team to increase your vitamin D level to get to the optimal range (top half of the lab’s reference range). See https://terrywahls.com/shop/ for tests you can order and obtain directly.

Here are some natural remedies I use often in winter to help me and my family avoid and treat illness.

1. Eat raw garlic, which boosts your natural killer immune cells. Daily consumption of raw garlic can help prevent illness and reduce symptoms if you aren’t feeling well. When I develop symptoms, I eat raw garlic four times a day. 
2. Drink fire cider, which is a combination of apple cider vinegar, garlic, peppers, horseradish, and other herbs that boost the natural killer cells. I take one tablespoon a day to prevent sickness and 1 tablespoon four times a day if I am already feeling ill. 
3. Get more vitamin C. Daily doses of 250 to 500 mg can boost immune cell activity and strength. We can’t make our own vitamin C. When we become ill, our vitamin C needs to increase. Nutritional biochemist Linus Pauling famously recommended additional vitamin C at the onset of the common cold (another coronavirus).  
4. Get more zinc. Zinc deficiency is very common in those with chronic disease. Adding a zinc lozenge (5 to 10 mg) during the winter may be a wise protective measure for anyone worried about COVID-19 risk. 
5. Consume more fermented foods such as kimchi and sauerkraut.  The probiotics in these foods help modulate the immune response, lowering the risk of septic shock in response to serious viral infections.  In addition, sauerkraut is a good source of vitamin C. 
6. Elderberry syrup has been shown to be helpful against the influenza virus. However, for  COVID-19 elderberry syrup may increase the risk of cytokine storm and more severe reaction. For that reason, I would NOT use elderberry syrup at this time.

My good friend Elisa Song MD is a pediatrician who has written a detailed article about COVID-19. If you want a more thorough analysis of the risk and discussion of what you can do to protect yourself and your family, read her article.

https://healthykidshappykids.com/2020/02/27/coronavirus-covid-19/

Here is a link to the CDC coronavirus site.

Look for your local public health resources as well.  Here is the Iowa coronavirus site.

https://hhs.iowa.gov/

Dr. Terry Wahls is an Institute for Functional Medicine Certified Practitioner and a clinical professor of medicine at the University of Iowa where she conducts clinical trials.  In 2018 she was awarded the Institute for Functional Medicine’s Linus Pauling Award for her contributions in research, clinical care and patient advocacy. She is also a patient with secondary progressive multiple sclerosis, which confined her to a tilt-recline wheelchair for four years. Dr. Wahls restored her health using a diet and lifestyle program she designed specifically for her brain and now pedals her bike to work each day. She is the author of The Wahls Protocol®: A Radical New Way to Treat All Chronic Autoimmune Conditions Using Paleo Principles, Learn more about her MS clinical trials by reaching out to her team: [email protected]. Pick up a copies of her research papers at https://terrywahls.com/researchpapers/ and a one-page handout for the Wahls™ Diet at https://terrywahls.com/diet/