Dead by design?

With the U.S. now the world leader by far in deaths linked to COVID-19, isn’t it about time Americans recognize there is more to this situation than simply the newly emergent SARS-CoV-2 virus?

The data on deaths increasingly links fatalities to physiologically unhealthy lifestyles, and much of the U.S. problem with physiologically unhealthy lifestyles is in turn linked to America’s love with the automobile.

Americans drive about 13,500 miles per year, according to the Federal Highway Administration. European Union countries average about 7,500 miles per year, according to an analysis done by the European Commission’s Odyssee-Mure project.

As of this writing, the World Health Organization (WHO) reports 505,000 dead in the U.S. and 859,000 dead in Europe. But Europe is today home to about 749 million people, according to the World Population Review. The U.S. population is estimated at 332 million at this time.

Adjusting for population, the U.S. has a death rate of 152 per 100,000, which compares to a European death rate of 114 per 100,000. But where the data gets really interesting is when the countries where people walk and bicycle as much as they drive enter the analysis.

Africa has suffered but 72,000 deaths, according to WHO, for an overall death rate of around 5.5 per 100,000. Death rates in Asia are similarly low. The Worldometer tracker puts the death rate in India today at 11.2 per 100,000. 

Motor vehicle ownership in India – where only seven out of every 100 people own a car – is a twelfth that of the U.S. – where 84 out of every 100 people own a car or truck. Huge numbers of Indians still get around by walking, bicycling, or hiring a rickshaw or pedicab.

Indians fleeing that nation’s cities on foot to return to their rural homes during the pandemic made international news.. An India-based reporter for the BBC reported meeting “a five-year-old boy who was on a 700 kilometer (434 miles) journey by foot with his father, a construction worker, from Delhi to their home in Madhya Pradesh state in central India.”

And what does this have to do with all those miles Americans drive?

Sedentary lifestyles

A peer-reviewed study published in the Journal of the America Heart Association last week links just shy of two-thirds of U.S. COVID-19 deaths, 63.5 percent to be exact, to four, pre-existing medical conditions: diabetes, obesity, hypertension and heart disease. 

The study’s authors from Tufts University and the Ichan School of Medicine concede these findings should come as no big surprise.

“Studies of clinical characteristics of patients with COVID‐19 in Wuhan, China, and Italy first suggested that diabetes mellitus, hypertension, and ischemic heart disease were the most distinctive and/or frequent comorbidities associated with severe infection,” they wrote. “Similarly, a high prevalence of cardiometabolic comorbidities were found among patients hospitalized with COVID‐19 in New York City (NYC) and Washington state. Cardiometabolic comorbidities including obesity, chronic cardiac disease, hypertension, diabetes mellitus, and chronic kidney disease have been further identified as strong predictors of COVID‐19 hospitalization among infected patients in NYC and of in‐hospital mortality in China and the United Kingdom.”

What the new study brings to the table is a big sample size – 906,849 U.S. cases – and a recognition that some of the underlying problems involve not just this pandemic but those possible in the future.

‘The strong links between these conditions and poor outcomes in COVID‐19 provide a compelling signal to clinicians and policymakers on additional approaches to improve population resilience for COVID‐19 as well as future pandemics,” they wrote.

The study’s findings, they said, support a “need for prioritizing vaccine distribution to individuals with cardiometabolic conditions” and continued use of so-called nonpharmeceutical interventions, but also “highlight the urgent need for trials to understand whether improving cardiometabolic health will reduce hospitalizations, morbidity, and healthcare strains from COVID‐19.

“Controlled trials demonstrate rapid improvements in cardiometabolic health from lifestyle changes. In randomized controlled feeding trials, changes in diet quality alone, without weight loss, led to improvements in just six to eight weeks…and if changes in diet quality included healthy dietary fats, insulin sensitivity also improved.

“In one trial, dietary guidance emphasizing healthful minimally processed foods, without any focus on energy restriction, resulted in an average, approximately 6 kilogream (13.2 pound) weight loss…with corresponding improvements in multiple cardiometabolic risk parameters. Increases in physical activity also significantly improve cardiometabolic health in controlled trials, even without weight loss.

“Given the estimated burdens of COVID‐19 hospitalizations attributable to cardiometabolic conditions, our results indicate a need to test whether even modest improvements in cardiometabolic health in individuals and populations, through clinical efforts, public guidance, or other public health actions, could have an impact.”

The need for improvements in cardiometabolic health is a tune doctors in the U.S. have been singing for a long, long time. Those involved with the now famous, 73-year-old Framingham Heart Study began talking about the threats of poor diets and lack of fitness decades ago.

Chicken-fat America

The detiorating physiological condition of the nation drove late President John F. Kennedy (JFK) to in the 1960s launch a national campaign to to improve physical fitness. Shortly after he took office, Sports Illustrated magazine published a JFK-written essay titled “The Soft American.”

The administration then took to promoting 50-mile hikes, according to the JFK Library, which records that “many Americans took the hike as a challenge from their president. The Kennedy council (on fitness) capitalized on this enthusiasm with a national publicity campaign on physical fitness. The campaign was organized, extensive, media-savvy, and above all, countrywide. 

“The oddest contribution to the effort may have been the ‘Chicken Fat’ song. Meredith Willson, creator of The Music Man, wrote the song. It was sung by Robert Preston, the star of the musical. ‘Chicken Fat’ was produced in a three-minute, radio-friendly version and a six-minute version to accompany schoolchildren during workout routines.”

With its lyrics of “nuts to the flabby guys!  Go, you chicken fat, go away!” it might today get Preston and Wilson roasted on Twitter for “fat shaming.” So many Americans are now fat that they really don’t like being reminded of it.

When Kennedy was president, the average U.S. male weighed 166 pounds. By 2010, the average female weighed the same, having increased from 140 pounds in 1960, and the average male had ballooned to 195.5 pounds, according to the U.S. Centers for Disease Control and Prevention (CDC).

Americans have only kept getting bigger since then. The CDC in 2018 reported almost three-quarters of the nation’s population was overweight or obese. 

Obesity is not a direct measure of cardiometabolic health, but as with rates of COVID-19 infections and COVID-19 deaths, when one goes up, the other starts climbing as well.

This is far from the fault of individual Americans themselves. A 2014 Stanford study that looked at U.S. diet from 1988 to 2010 found Americans weren’t eating any more calories in 2010 than in 1988, they were just burning a lot less because they spent less time moving.

The peer-reviewed study published in the American Journal Medicine (AMJ) pointed the finger at “leisure-time physical activity,” but that isn’t the only place where Americans now burn fewer calories. Day in and day out, a lot of Americans spend too much time sitting on their asses.

Cities designed around motor vehicles largely dictate such behavior.

“There is no easy answer in our ongoing battle against obesity, but identifying the link between the drop in physical activity and increased body mass indexes (a measure of obesity)…can assist public health officials to develop targeted, effective interventions,” the AMJ observed on its blog in the wake of the Stanford study.

“If we as a country truly want to take control of our health and our health care costs, the Ladabaum et al paper should be our clarion call,”  AJM managing editor Pamela Powers Hannley in an accompanying commentary. From encouraging communities to provide safe places for physical activity to ensuring ample supply of healthy food to empowering Americans to take control of their health, we must launch a concerted comprehensive effort to control obesity.”

Not moving enough

The link between the lack of physical activity and obsesity is obvious. Americans use human power less and less to get around.

A 2016 Brookings examination of how Americans get to work found less than 3 percent walk and less than 1 percent cycle. More than 75 percent get in a motor vehicle and make a lone drive, the think tank discovered.

Not many calories are burned by people sitting behind the wheel. And it’s not just work to which people drive; it’s to almost everything. For decades, motor vehicles have dictated how cities grow with residents in one area and businesses, including supermarkets and grocery stories, in another with a motor vehicle required to get between the two.

American waistlines have tracked this evolution.

“Each additional hour spent in a car per day was associated with a 6 percent increase in the likelihood of obesity,” a peer-reviewed study in the American Journal of Preventative Medicine reported. “Conversely, each additional kilometer walked per day was associated with a 4.8 percent reduction in the likelihood of obesity.”

There has been a nascent movement to redesign cities to get people moving, but it has gained little traction despite being sold as a way to cut down on motor vehicle use and thus help slow global warming.

Public health might, however, be a more immediate and pressing issue of concern. The connection between chronic, sedentary-lifestyle-linked illnesses and COVID-19 deaths is making it harder and harder to ignore the issue of fundamental fitness, even if the lack of it has been killing Americans for a long time.

Framingham data long ago indicated that sedentary lifestyles were making Americans ill and shortening lifespans by years.

“Avoiding a sedentary lifestyle during adulthood not only prevents cardiovascular disease independently of other risk factors but also substantially expands the total life expectancy and the cardiovascular disease–free life expectancy for men and women,” Dutch and Australian researchers reported in a peer-reviewed study JAMA, the Journal of the American Medical Association in 2005. “This effect is already seen at moderate levels of physical activity, and the gains in cardiovascular disease–free life expectancy are twice as large at higher activity levels.

An in-depth examination of Framingham data, they said, led them to the conclusion that on average “moderate and high physical activity levels led to 1.3 and 3.7 years more in total life expectancy and 1.1 and 3.2 more years lived without cardiovascular disease, respectively, for men aged 50 years or older compared with those who maintained a low physical activity level. For women the differences were 1.5 and 3.5 years in total life expectancy and 1.3 and 3.3 more years lived free of cardiovascular disease, respectively.”

And there were pre-COVID-19 studies indicating the gains could be even bigger. When cardiologist Dr. Benjamin Rosin undertook an examination of 54, serious, old marathoners in California in 2107, he discovered they were, on average, living 19 years longer than comparable, inactive men who had reached age 40 in 1975.

The average age of the 18 runners who died between ’75 and 2017 was 81. Seven died of cancer – the nation’s second-leading killer – at an average age of 77.2  Heart disease – the nation’s leading killer – claimed the lives of five, but not until they’d reached the average age of 86.

Rosin conceded the marathoners collectively benefitted from high social-economic status (SES), a known protectant against all forms of illness and disease, including COVID-19. But that alone could not fully explain the difference between their long lives and the shorter lives of non-exercising contemporaries.

And now?

Scientists studying the reasons why athletes engaged in intense training programs become more vulnerable to infections 14 years ago reported “type 1 T cells promote cell-mediated immune responses, which primarily provide protection against viruses.”

“Regular moderate exercise” helps strengthen T-cells, they reported in a peer-reviewed study in the Journal of Applied Physiology. “However, prolonged bouts of strenuous exercise cause a temporary depression of various aspects of immune function…that usually lasts 3 to 24 hours after exercise, depending on the intensity and duration of the exercise bout.”

Researchers studying COVID-19 have identified T-cells as the most important natural response to the virus.

There is no doubt getting people fitter and healthier through moderate exercise would boost T-cell performance and save lives, but the urban and suburban landscape of a modern United States largely designed to accommodate the automobile doesn’t encourage getting people healthy.

The result is the U.S. might be the world leader in COVID-19 deaths by design.