Dr Casey Means, Chief Medical Officer of metabolic health company Levels believes that the COVID-19 pandemic will be particularly challenging for the 77 million Indians living with diabetes as social distancing and lockdowns could negatively impact such patients who lack regular exercise. Therefore, they must make several nutritional and behavioural changes to improve their metabolic health amid this pandemic. She also explains to Viveka Roychowdhury why a concerted effort towards improving foundational metabolic health may prove to be an extremely high-value approach during the COVID-19 epidemic
Since we do not yet have a cure for SARS-nCoV2 yet, the COVID-19 pandemic has focussed attention on the need for long term preventive strategies, especially for chronic lifestyle-related conditions like hypertension, diabetes, etc. India has a high disease burden of such conditions so do you feel the right strategies are in place to help these patient populations cope with their conditions during COVID-19 lockdowns?
India is estimated to have over 77 million people living with diabetes and around 30 billion with obesity, both diseases that have been linked to increased mortality from SARS-CoV-2. It is also known that improved glucose control is significantly associated with better COVID-19 outcomes, so anything a government can do to support widespread glucose control may impact COVID-19 mortality. Given that food choices are a major contributor to glucose levels, support of programmes that increase access to metabolic health-promoting foods at scale (like vegetables, low-glycemic fruits, nuts, seeds, beans, and legumes), is likely to be a high-value intervention.
To date, the Indian government has taken many strong policy steps to respond to the virus, including travel advisories, social distancing and hand hygiene campaigns, a Containment Plan based on zones of COVID-19 impact, surveillance through swabs and serum testing, contact tracing, instatement of a curfew, and designating specific public health facilities for COVID-19 case management. A recent policy report  from June 2020 assessing India’s response to COVID-19 highlighted a number of challenges still facing the country, including a doubling of cases since May 1st, low testing rates early on in the pandemic, and slow (but growing) domestic production of testing kits.
In addition, there is some evidence that the COVID-19 response has disrupted other healthcare services, like inpatient and outpatient treatment of many common diseases including diabetes and high blood pressure. Furthermore, research suggests that surveys of people with type 2 diabetes show that only 28 per cent of the surveyed individuals are checking their blood glucose levels regularly. Other papers have speculated on barriers to self-management of diabetes including poor access to diabetes resources, limited adoption of telemedicine due to lack of definite legislation on this medium of practice, culturally entrenched food preferences, and lack of confidence in importance in home-based care in diabetes management. Unfortunately, researchers in India have modelled that due to lockdown, there is expected to be a significant worsening of glycemic control and diabetes-related complications such as retinal disease, kidney disease, diabetes-related amputations, heart attack, and stroke.
Any country facing comorbid epidemics of diabetes, obesity, and COVID-19 will benefit from a swift and coordinated effort focused on fundamentally improving metabolic health. This includes strategies for optimising nutrition, exercise, sleep hygiene, stress management, and toxin exposure, all of which have been shown to be involved in improving metabolic health. Additionally, rapidly increasing access to continuous glucose monitoring technology, which makes glucose monitoring significantly more granular and simple, and telehealth medicine and coaching, and can contribute to increased metabolic fitness, is another important step. Researchers in India recently published that for individuals with diabetes in India, their “blood sugars need to be better controlled and their health condition needs to be better monitored, even in the face of lockdown, through measures such as teleconsultation and telemedicine.” Type 2 diabetes and obesity are both largely preventable, and often reversible with healthy living strategies, so a concerted effort towards improving foundational metabolic health may prove to be an extremely high-value approach during the COVID-19 pandemic.
What are the strategies that policymakers as well as practising physicians in India need to put in place to ‘nudge’ patient populations to make these changes?
India — along with every other nation in the world facing obesity, diabetes, and cardiovascular disease epidemics — will benefit from multifaceted approaches that promote sustainable healthy living, which may span addressing and optimising health systems, economic incentives, school and workplace environments, quality and labelling standards, and innovation and entrepreneurship. This might include supporting the production of “protective foods” such as minimally processed, phytochemical-rich fruits, vegetables, legumes, nuts, and seeds, and disincentivising production of disease-promoting foods like refined grains, sugars, and processed meats. An additional approach could include increasing access to technology to allow individuals to make smarter food choices, such as continuous glucose monitors which can help guide a person to choose a metabolically-optimised diet. As of the last couple of years, India has recently upped its subsidies for sugarcane.
Dr Means, why did you transition to Functional Medicine in March 2019, after training to be a Head & Neck Surgeon at Oregon Health & Science University Hospital?
During my training in head and neck surgeon, I treated many diseases that had their root in inflammation, like chronic sinusitis (inflammation of the sinuses), Hashimoto’s thyroiditis (inflammation of the thyroid), vocal cord granulomas (inflammation of the vocal cords), and chronic ear disease (inflammation of the tissue of the ear). The pervasive theme of inflammation caused me to step back and think about the root causes of inflammation: why were so many of my patients inflamed, and mounting an uncoordinated and maladaptive immune response?
I realised that surgery may minimise current symptoms, but doesn’t necessarily address the triggers of inflammation that frequently set off the disease. This journey led me to understand that much of what contributes to inflammation is rooted in diet and lifestyle, like what we eat, our level of metabolic health, how we manage stress, how much or little we exercise, the status of our microbiome, and the quality of sleep that we get.
What’s more, aside from conditions of the head and neck, many of the chronic diseases that plague our globe, like cardiovascular disease, diabetes, and obesity, are also rooted in inflammation. Functional medicine approaches symptoms from a root cause perspective, addressing the core biologic pathways that often underlie many seemingly disparate diseases. By addressing symptoms and disease at the root cause level, there is the potential to have a wide-reaching impact on health with simple health-promoting interventions.
The adage to let ‘food be thy medicine’ is something that all cultures and civilisations around the world prescribe but it’s easier said than done! Is there an equivalent to the evidence-based medicine approach in functional medicine?
Functional medicine aligns with this adage as well. As an example, by analysing one’s diet through the lens of how glucose levels change in response to particular foods, we see evidence of food choices being core to optimising metabolic levels and one’s health. Keeping glucose levels steady over time leads to better health outcomes, and glucose levels are in large part a result of the food we put in our bodies. India has always been a leader in using food as medicine, with Ayurvedic concepts dating back millennia, with an emphasis on universal interconnectedness of earth and body, and the importance of food as part of the way that the vital life force (prana) sustains health.