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COVID-19: Functional Medicine and Paediatrics with Dr Elisa Song

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COVID-19: Functional Medicine and Paediatrics with Dr Elisa Song

In this podcast integrative GP, Dr Mark Donohoe and functional paediatrician, Dr Elisa Song chat about COVID-19 through the lens of functional medicine.

Elisa and Mark discuss what we know so far in this emerging pandemic and what dietary and lifestyle options show efficacy and evidence, but are also safe choices for empowered preventative healthcare.

**This interview was recorded on 8th April 2020 and is also available as a video podcast on the FX Medicine Facebook page.

Covered in this episode

[00:18] Welcoming Dr Elisa Song
[00:46] The current COVID-19 situation in paediatrics
[03:18] What's driving kid's immune plasticity & resilience?
[07:36] The value of dietary intervention 
[09:34] The psycho-social disaster 
[14:01] Physical distancing, not social isolation
[15:36] Essential elements to maintaining wellbeing
[18:14] The health benefits of practising gratitude
[20:41] Vicarious re-traumatisation 
[25:09] Implications for pregnancy, newborns and infants
[31:52] Food and supplements to support wellbeing
[39:41] SARScoV-2 and the cytokine storm picture
[43:14] Pulling positives out of the COVID crisis


Mark: Hi, everyone. I'm Dr Mark Donohue and welcome to FX Medicine. Today, I'm standing in for Andrew Whitfield-Cook, and we're talking about the coronavirus in kids with a very good friend from a couple of years back at the BioCeuticals conference, Dr Elisa Song. Welcome, Elisa. How are you going?

Elisa: I am doing great, Mark, and I'm really honoured to be here and share whatever information I can with all of you in Australia because this COVID-19 is really affecting all of us worldwide.

Mark: I should actually put it in perspective. We're talking here on April the 8th in 2020. It's a big time in America and it's a big time in Australia for the expansion of the SARS-CoV-2 virus. It's making a living in a lot of people and causing a lot of havoc. But I do have to say, although the world's in lockdown, it does seem that, as a paediatrician, you have the luxury of having the only patients in the world who are relatively immune, or I shouldn't say the word immune, but not being affected as severely by the virus. Is that what you're finding or are kids getting sick with this already?

Elisa: Some kids are getting with it but worldwide we are seeing that the vast majority of children who are diagnosed or presumptively diagnosed with COVID-19…so just in terms of the terminology, SARS-CoV-2 is the name of the virus that is causing the respiratory illness COVID-19. They're sometimes used interchangeably but COVID-19 is the clinical picture of what's going on.

And so even now, worldwide I just looked today at the Johns Hopkins database, and we have a little over 1.2 million people who have been infected worldwide. Even within that number, we're finding that the vast, vast majority of children seem to do well with their illness, have mild to moderate symptom, don't require serious interventions, hospitalisations, intubations. And even in that number, we are finding that, even worldwide, there's been fewer than 5 recorded deaths in children under 19. 

Mark: Right.

Elisa: So it is true somehow children seem to be relatively spared. Now, the other thing, too, is, though we don't know given the paucity of testing here in the States and really worldwide, I don't know how Australia has been doing in terms of rolling out testing on time. But here in the States, we are woefully slow to getting our testing rolled out. In other countries like in Iceland, they just realised as they're rolling for testing that maybe up to 50% of the population is asymptomatic and has had COVID-19 or has COVID-19. 

I do suspect that many, many children are asymptomatic carriers, and this is where the lockdown, the shelter-at-home, the quarantine is so important to help slow down the spread to those vulnerable populations.

Mark: It does seem that way. The degree to which children are capable of managing these kinds of infections...as a paediatrician, you've obviously seen this. You see kids with terrible infections but also their ability, the kind of immune plasticity and flexibility of them. Why are they doing so well? Why do children handle things so much better? And why do we lose that capacity as we age? What goes wrong?

Elisa: Well, that's been actually really puzzling to researchers, and I think if we could figure out why children seem to be relatively spared, we would understand a lot more how can we help prevent serious complications in our adult patients. Because we do know that, even so...I mean the numbers, when you look...and I've stopped looking at the Johns Hopkins map every day. As you said, this is April 8th as we're speaking. Whenever this airs, that number that we see on the map is going to be significantly higher as more and more people get affected. 

But over 80% of patients do recover and do seem to have mild to moderate symptoms. So I want to really acknowledge that first and foremost. But children, in general, they don't have all the garbage that we've built up over time. In Italy where the death rates have been so tragically high, they still have found that 99% of the people who died in Italy had one, two, or three, or more chronic health conditions. I think children just haven't had the time to build up our chronically poor lifestyle that leads to all of those chronic illnesses.

But the other conjecture, too… I actually had to laugh a bit because I read this one article that was conjecturing that children may have relatively lighter symptoms because they eat healthier. I don't know about they're eating healthier but certainly not in the States, right, with the standard American diet and the white diet with mac and cheese, and pizza, and quesadillas, which are pretty much all the same food, and all the sugar. I really don't think it's the diet. I think there is some thought that children have higher levels of melatonin, and we do know that melatonin does seem to be actually protective in terms of COVID-19 infections.

The other thing, too, is that the SARS-CoV-2 enters the cells through ACE2 receptors, and ACE2 receptors are primarily located in the lung, intestinal lining, and the liver. Another thought is that, because children, their lungs are less mature, they have fewer ACE2 receptors for the SARS-CoV-2 virus to enter. That could be a possibility, too. I mean this is all theory, but what I'm finding is that children seem to be presenting more with gut symptoms with diarrhoea, and the tummy aches, and the nausea. They do have quite a few ACE2 receptors in their gut lining. It may be something to do with that.

Mark: I've been listening to some of the clinicians in New York saying that the worst-case outcomes are being predicted somewhat by adults who get diarrhoea as the earliest sign. They don't, in fact, feel that they have a cough or a cold. 

Elisa: Yeah.

Mark: It seems like that binding to the ACE2 receptors in the duodenum might be a real thing, that the virus gets in and gets on to an unhealthy gut, whether through drug therapy, dietary, whatever you like to say, and has a free period of time to breed up a little bit without the obvious symptoms.

We've had this problem all the time—asymptomatic people are passing it on. It does seem that there's way more of this gastrointestinal, the diarrhoea-like illnesses, feeling unwell but not a classic cold and then the respiratory symptoms coming on secondary. So it is interesting. ACE2, we all think of it, "Oh, pneumonia is the only thing," but in fact the gut is a good breeding ground for a virus like a coronavirus.

Elisa: It is. That's interesting, too.

Mark: I take issue with the kids...sorry, I take issue with the kids and teenagers who you see all the time. As you know, I've seen the work on your website to try and get them to eat well. The work that has to be done. Junk food is the living aim. Especially now people are locked down at home, I would guess their diet hasn't greatly improved either in that time. If we could get kids to eat well, that may be an additional benefit but it does seem that the dietary management of this, getting the gut right, is going to become an important part. Diet, anything that we could do to get a healthy gut may just be a barrier as well.

Elisa: Yeah, absolutely. One thing that I'm really, really talking to parents about and children about, during this time, when we’re really trying to support our immune systems. It is such a stressful time for everybody. Life has been turned upside down for everyone, and the ultimate not just physical toll, but the emotional, psychological toll and the economic toll that many of us will face, long after COVID-19 is no longer a pandemic. Many of us are reaching towards our comfort foods, and a lot of that includes sugar. And I'm telling people do not stock up on sugar in your grocery carts. Don't reach for that pint of ice cream when you're stressed out. Find other ways to manage your stress because that's the worst thing we can do when we're trying to support our immune systems.

This is an old...I believe it's from the '70s or the '80s but this one research paper found that not just refined sugar but even fructose could within 20 minutes suppress the ability of our macrophages to do their job and mop up all of the virus and bacteria by 50%. The effect lasted for at least 5 hours. So as we're really trying to make better choices or educate our families how to make those good choices for immune systems, sugar is one of the first things that we have to really think about cutting back on.

Mark: I mean I have another concern. You lock teenagers and kids in a house with their parents and don't let them leave home. Surely, there is a psychological disaster brewing there. I mean I think of me, if I was 12, 13-year-old, and I was locked up with my parents and maybe younger kids and couldn't get out. There has to be an impact on people not going crazy. 

Do you have advice on that side of how you get through this? How do you stay together in a home, not leave, and yet not go insane? But I have this feeling that, at the end of the lockdown, we'll be going around home seeing that there are dead people that were killed by other relatives in their homes other than the virus.

Elisa: Yeah. Well, the problem is very real. We've just seen that there is one report that came out. I'm sure we're going to see larger numbers of this, of people with mental health problems with depression and anxiety or schizophrenia or you name it, who are essentially locked at home without social connection with their friends or family. This one man took his own life. And so I think that we really do have to think about what this lockdown means.

Now, in California, we were the first state to have a statewide shelter-at-home order, and it's not a lockdown per se. I mean, we are allowed to leave our homes for essential items. We're not stuck at home. I know there are certain countries where that is the case, but at least, for us, we can be outdoors and go for walks and bike rides. I definitely think that getting outdoors in the sunshine, in nature is really, really important for everyone's mental and physical health.

People are not moving their bodies, and I really worry about that. One of my receptionists...she told me it's fine for me to share this, but we just had a good laugh but then kind of a horrified laugh because her fiancé who is now working from home, she came home one day and looked at his smartwatch, whatever, step counter. He had only taken 93 steps the entire day and I'm like, “how do you do that?” Did he not go to the bathroom or go to the kitchen to make some food? But I am fearful that many people are doing that. They're staying inside at home, on their butts, not moving, and we are not going to come out a healthier society for that. So I do think that this is our opportunity to really get back to the basics of a healthy lifestyle, diet, good habits.

But in terms of family units and really surviving inside the house without driving each other crazy, I think that really… We all know about adverse childhood events and the lifelong implications for chronic health disease. I think, for many of our kids, this will be an ace for them and so we need to do our best to try to mitigate that, help really build up that emotional and cellular resilience for their lifetime.

One of the keys for all of us right now is we need to maintain our routines. The structure of our routines is different but having those routines especially for teenagers. This is not a free-for-all. It's not summer vacation. It’s not a weekend. We all need to get up, shower, wash our faces, change our clothes. It is not time to stay in our pyjamas all day. I tell all teenagers they cannot lounge around in their pyjamas all day in the same set of pyjamas for the whole week. That's not acceptable.

My kids are 10 and 8. One of the first things we did when we were told that we would be doing distance learning, online learning, with school...and it was just announced today that this would extend for the rest of the school year. Our kids are not returning to school for the rest of this academic year. I don't know if you could see but we literally came up with a spreadsheet. Thankfully this is my first draft but, you know, a spreadsheet from 8:00 in the morning to 8:00 at night in half-hour increments and we wrote down when we're going to have breakfast, when it's time to do schoolwork, when it's time to go outside, when it's time to exercise. We don't have to follow it to the T, but predictable routines make everyone feel safer.

The other thing, too, is we really want to try to move away from the terminology of social distancing. That's a term that's really come up with "flatten the curve". We want to socially distance so that we prevent the spread through respiratory droplets. But social distancing should not equal social isolation, and we want to really think about this in terms of physical distancing, we are physically distancing ourselves from others to keep ourselves and others safe and healthy but socially...I mean look at how we're communicating? We're on opposite sides of the world, right?

Mark: Yeah.

Elisa: We have to maintain that social communication which is really key. So, for our younger kids like my children who don't have their own Zoom accounts or don't have their own devices, we are scheduling Zoom play dates or FaceTime play dates, and family FaceTime and Skype meetings so that grandma and grandpa who we're staying away from can maintain contact. It's especially important that during this time our kids, they are going to get more screen time than we would like. It's just going to happen, but we need to be mindful of that and be aware of how they're using their screen time and help facilitate that.

Mark: Right. The conspiracy theory is either the Zoom corporation or Netflix engineered this whole crisis so that we can stay at home, consume all video, use more bandwidth, and it's tempting to think sometimes that's the case. 

In Australia, we have more of a lockdown than I think anywhere, but maybe New York is getting to that level. But in Australia, the degree in which you could get out, people are borrowing other people's dogs so that they have an excuse to get out of the house to walk the dog. I know full well we're just coming out of summer heading towards winter down here. The value of good sunlight exposure, exercise, vitamin D, especially for upper respiratory infection when you're trying to keep that under control, if you lock everybody inside and you give them no way of moving the muscles, then the body falls into an unhealthy state. 

Elisa: Yes.

Mark: The dropping vitamin D and that kind of… We're almost emulating a little bit of inability to do something and the body goes into a state which is not healthy. Trying to maintain health in this stage may be getting a new hobby like cooking. Especially for old men like me who are at risk, we should be cooking for ourselves for a change. Doing something on our own diet rather than relying on our partners. 

But new skills, getting outdoors, if you had a checklist of things just to say, during this time, what am I going to be advising not just your paediatric patients but the parents in the household to do? What would be your favourite list of things? I know food is going to be on there, and I know it's going to be very high. I know that there's a rainbow coming, but what would be your checklist? Just a rundown.

Elisa: I love that you said finding something new to do. I think that we need to really use this time to keep our brains and our minds as active and healthy as possible, not just our bodies. 

Mark: Right.

Elisa: In all of this, we have to see through the tragedy there are going to be some golden opportunities that we will never have in our life again. We will never have this time to spend this much good time with our immediate family. It's just not going to happen in this way again. So really thinking about how do we want to use this time.

And so coming up with a new hobby, a new skill. Cooking for sure is a great one. My kids actually just learned how to make scrambled eggs and a breakfast sandwich so that they can make it for us in bed on Saturday mornings. It can be really fun things, too. My daughter is learning how to make all sorts of things with origami now, and just folding all these amazing creatures. I know I want to learn how to knit. So if there's ever anything on your bucket list, this is the time to pull out, find a YouTube tutorial, and do that.

Mark: Right.

Elisa: The other thing that really is going to be very, very important for all of us during this time is to figure out how we can practice gratitude every day. We know this hype behind gratitude, that gratitude is not just something for me to feel good. It really does increase our heart rate variability. It's going to increase our sense of connectedness with our family, and our friends, and our communities, and even the world.

And so that's something that I teach kids, and parents, and adults. It's probably more important for parents and for teenagers because the younger kids right now, they're not so stressed. We do have the ability still to shield them from a lot of what's going on in the world. But it's really our teenagers with free access to their devices and scrolling their media feeds, and seeing all the horrible news and not able to filter it out, and don't quite have the maturity yet to really sort out the news for themselves. They're the ones coming in with panic, and stress, and anxiety for all of this.

Mark: Yes.

Elisa: And so, when we can teach them to do things like HeartMath and diaphragmatic breathing, practice gratitude in a specific way. I mean there's loving-kindness gratitude that I love to teach kids and adults. It's just four sentences that they repeat. First giving that loving-kindness to themselves, and then thinking about their friends and family, and extending that same loving-kindness. And then thinking about their community, the healthcare workers in the frontlines, thinking about their country, of the world, and really extending that out. The sense of calm that you get is incredible. 

The four sentences, all they have to repeat is "May you feel safe. May you feel healthy. May you feel happy. May you live with ease." And that's it. I mean it's four sentences that really…Those four sentences they actually gave college students to do a loving-kindness meditation every day for six weeks. They had seen improvements in their heart rate variability. They have seen improvements and feelings of connectedness with others, which is so important right now where we can so easily feel isolated.

So this is a time to really figure out what's going to bring us joy. What do we want our life to look like after COVID-19 because there will be an after, and so we want to make sure that we not just survive through COVID-19 but that we thrive and that we can build a purpose during this time and beyond.

Mark: In a way, it's a kind of opportunity. It doesn't feel like it when the panic button is hit. 

Elisa: Yep.

Mark: I do understand the seriousness of the degree to which our officials have to be very almost super pessimistic to get people to do what's good for them. But we do have a next-generation who are not those that are suffering from this who are watching their parents and officials, and watching the panic. I fear that they're modelling off us. That as a youngster, they watch how we handle stress. That modelling has the risk of depressing immunology at a very literal sense. Joy, happiness, gratitude tend to enhance immune responses that are protective. Whereas going into your shell, hunkering down, feeling under stress is definitely not a great way to get a good, balanced response to a virus.

So I have two concerns there. One of them is, what's the psychology of going into fear as your response to something that is a threat around, rather than going into joy, gratitude, and finding new hobbies in your life? At the end of it, are we just setting the stage for more of these kind of episodes in the future? Because viruses are going to make their move on us. They are going to come out of that somewhere. There's one breeding up for us in another decade. This isn't the last of the ones we're going to have to face. I wonder if we're just modelling the wrong things there.

Elisa: Right. I mean you bring up so many key points because, as I mentioned, I do think this will be a serious adverse childhood event for many of our kids. They absolutely, especially for our younger kids, when we're going through a traumatic experience like this, a world disaster, whatever it may be, our kids are watching how we're acting and what we're saying to inform them how they should be responding to trauma and to traumatic events. That's important then, to how they should be responding to any stressful event in the future.

When we are panicking, afraid, nervous, frustrated, angry, whatever the range of emotions that we're feeling, we do want to acknowledge that we're feeling those emotions but, if they're really complex and complicated and if we're literally freaking out, we just need to step away, process those feelings, and come back and talk with our children about what we're feeling and what they're experiencing. Very, very important.

The other thing, too, is in terms of taking media breaks, it is really crucial that we do not have the TV or the radio on as background noise. We don't have our social media feed constantly up because children will be… There's a term called vicarious re-traumatisation where they keep hearing...and we are doing this to ourselves, too. We are now vicariously re-traumatising ourselves. We're doing it on purpose. But children, as they see and hear these things on the news over and over again but don't quite understand what to make of it, how to interpret it, they are vicariously being re-traumatised and so we really need to be careful about that. This is what we saw with the 9/11 attacks, that was happening when people just had the TV on all the time.

And I just want to point out, there’s a wonderful book by Dawn Huebner for children. And she didn't write this book obviously for COVID-19 because it didn't exist when she published this book back in the fall of 2019, but it's called "Something Bad Happened" and it's a way to teach children cognitive behavioural techniques to cope with bad news in the world. When she talks about the psychology of bad news, when our brain is in high alert and we perceive that we're in danger, the fascinating thing about our brain is that we actually look for signals to confirm to ourselves that we truly are in danger. 

Mark: Yeah.

Elisa: So we have to purposefully and actively look for those safety signals. We need to first get our brains out of the high alert state in order to be able to then see, "Okay, let's look to see what's safe around us, and what we can do positively to impact our safety and our well-being." That's all with the gratitude, mindfulness, improving our heart rate variability. These are skills...if our kids can learn these now when they're young through this traumatic time in our lives, they will have the skills to be resilient for the rest of their lives. I do think this is  a process to remember.

I do worry about the unborn generation or the newly born generation of babies. Not so much for the physical symptoms because we're finding that newborns and infants, they may have some complications with their hospitalisations but they absolutely are not dying at higher rates. They don't seem to have higher rates of complications than other children.

But now in the States, and I'm sure this will happen in other countries, for women who are delivering right now, many hospitals have limited the birth partner to one. So if you had let's say your husband or your partner and a doula, you can't have them both.

Mark: Right.

Elisa: Some hospitals are restricting access to anyone in the birthing room except for the mother and the delivery staff. We have these women who are labouring on their own, having their babies on their own, not experiencing the joy that they were anticipating.

And if they have diagnosed COVID-19 or presumed COVID-19 based on symptoms, the CDC just came out last week with a recommendation that mothers and infants be separated from birth for that time and those infants be put in their own isolation rooms which, to me, have devastating consequences for the bonding of the mother-baby. Of course, nursing is likely not going to happen successfully. We know all the amazing benefits of breast milk for the baby's developing brain, and gut, and immune system. So I worry that we're not thinking long-term enough about the health of our young ones.

Mark: I have heard the argument put now quite vigorously that we should be moving on to cesareans only. That this is a time for sterility, move away because the virus has been found in the gut, and so this fear of the virus. My understanding is that pregnancies so far, although we haven't had a full pregnancy for someone with COVID-19 but the pregnancies so far, it doesn't seem like the babies are affected or infected. The breast milk appears to be clear of the virus. 

Elisa: Yes.

Mark: There doesn't seem a reason to panic around birth, but it is I think medicine, our profession, going back to basics which is “Kill every bug. Allow for no bacteria.” That idea of sterile humans, the sterile Earth as the only safe place to be has lost all contact with our need to be part of the environment. The baby being born into that environment, being protected by the birth, the breastfeeding and the mother in the first maybe 6 months of their lives.
Elisa: Absolutely.

Mark: Have you heard anything about... The outcomes of pregnancy are only just starting to appear. As I understand it, there was one baby that was found positive for the SARS-CoV-2 after birth. No illness or anything associated with the mum. But I've seen no evidence that there could be bad outcomes or likely to be bad outcomes from going through a normal birthing process with normal contact in the birthing room. That seems to be being born into the world that we now find ourselves in which is the safest way to birth.

Elisa: Yeah. There are some larger numbers now of pregnant women. Initially, out of China, there was a...it's just an observational study of nine pregnant women who had confirmed COVID-19, all whose babies were discharged without any consequence, without a SARS-CoV-2 infection. In looking at breast milk, the placenta, and cord blood, there has been no SARS-CoV-2 found. So vertical transmission does not seem to be really a concern. 

Mark: Right.

Elisa: The cases of newborns who have contracted or been found to have SARS-CoV-2 infection, it does seem to be postnatally acquired. And so in my…
If mothers are testing positive for SARS-CoV-2, I think that the very best thing would be to breastfeed, because they have those antibodies that are passing to the babies. I see this all the time in mothers who have influenza, and their babies come out literally unscathed if they're nursing, because they're getting all these amazing protective antibodies. 

And then we also know the long-term consequences to the dysregulation of the baby's gut microbiome if they're born by cesarean section and if they are formula-fed from the beginning without the benefit of mum's milk, especially if they're separated from birth, with increased risk for atopic illness and allergies and ADHD, and you name it. All of those chronic health conditions that are going to put them eventually to a higher risk for something like COVID-19 in the first place.

Mark: Yeah.

Elisa: So we need to really, from a functional medicine perspective, put everything into context and see how do we not just reduce the risk now but reduce the risk long-term so that we actually have a healthier population in the long run.

Mark: It's the time to be a pessimist right at the moment. The upside we have here in Australia that, if you're the pessimist that says terrible things will happen, then if terrible things happen, then you were mystically fore-knowledged and you are blessed. 

If they don't happen, you just say, "Well, that's because people paid attention to me and nothing bad happened." The time to be an optimist is not now because things will go wrong. People do die, and this seems to be a pandemic which selectively chooses the older people with illnesses that are sooner or later going to take them anyway. That's the predominant loss of life. And though it's tragic, it is still…the 75 plus. I'm approaching these ages, so I'm not being flippant about it. 

But, given that that's the case, the people who are strongest and most capable of managing would appear to be the young mothers with their own immunology protecting them, passing on to the baby, and the baby growing up vigorously strong. This becomes one more virus, one more coronavirus that babies are good at handling, that is not a threat to society in the future. Whether or not there's a vaccine developed quickly or slowly, you still want a vigorously strong immunologically intact group of youngsters to be able to defend themselves like they do against every cold virus every year of their lives.

Elisa: Yep, absolutely.

Mark: So, is there a place... There's a lot of discussion going on about what to take. Donald has been helping not at all by getting up there and promoting Plaquenil, which I just learned today. There's an exposé suggesting that he's got shares in Sanofi, which doesn't surprise me at all.

Elisa: I wouldn't be surprised either.

Mark: But is there, I mean we’re stabbing around, people are in the dark saying, "Try this, try that." I know that your basic practice is built on food and love and care, gratitude. Are there particular foods or particular supplements? Is there anything that people can do even if it's only to settle their own sense of feeling in control, of not being just vulnerable out there and ready to be hurt by something? What's safe, likely to do no harm, and likely to provide some benefit?

Elisa: Yes. So I think that really the idea of taking back some control, taking back some power is really important because, in all of this, we have less than four months of data around the SARS-CoV-2 virus, right? It was first recognised less than four months ago or, I guess, announced to the world on December 31. We really don't have a lot of data and what we do know, what we could theorise is the data that we have from SARS-CoV-1, the SARS epidemic that hit the early 2000s. And we do have some data there, about some nutrients that may be really important.

We also know that, for patients with SARS-CoV-2 or COVID-19, there's talk of the "cytokine storm" and people's immune systems going haywire. 

Mark: Yes.

Elisa: These inflammatory cytokines—IL-6, IL1B, TNF-alpha—that are going crazy. We have to remember it's not so much that inflammation is a bad thing. It's just that inflammation unchecked. When we don't have the proper antioxidant reserves to really manage our own inflammatory response, that's when things can go a little haywire and really lead to poor outcomes.

So the nutrients that, you know, when I’ve been looking at the research and really trying to find “where is the evidence?” And, as you said, is there some evidence? Because we don't have a ton of evidence, but we have some. And what's also likely to be safe? So I do believe that the most important nutrients right now to really help prevent us from serious COVID-19 infection is going to be zinc, quercetin, vitamin C, and glutathione. If I had to choose four supplements, I would choose those, but I would try to find them in foods. Because those are really, really easy to find in foods that are very healthy for you.

Mark: Yeah.

Elisa: Why zinc? Zinc was actually found to inhibit the SARS-CoV-1 virus replication. Theoretically, there's about 80% concordance that SARS-CoV-2… The reason why it's called SARS-CoV-2 because it initially was called the 2019-nCoV but now realising that there's about an 80% or more similarity between SARS-CoV-1 and this virus, SARS-CoV-2, we can theorise that some of the nutrients that were found to be helpful against SARS-CoV-1 could be helpful against this current circulating coronavirus.

Zinc may inhibit replication of SARS-CoV-2. And why not get zinc from food? Pumpkin seeds are one of my favourite sources of zinc. You can grind pumpkin seeds, put them in your oatmeal, put them in your salads, put them in your soups, and you could put them anywhere. Of course, zinc intake is most closely correlated with animal protein intake. Cashews and sesame seeds, those are amazing ways to get zinc.

Quercetin. I love quercetin. Here in the States, we're in springtime allergy season. A lot of people use quercetin for their allergies, but what's very interesting is that quercetin is what's called a "zinc ionophore.” So it helps shuttle zinc into your cells. 

Mark Right.

Elisa: You want the zinc in your cells. If SARS-CoV-2 has been able to attach to those ACE2 receptors, we want zinc inside to inhibit that replication. So if quercetin helps enhance that, then great.

The theory behind why Plaquenil (hydroxychloroquine) may be beneficial is because hydroxychloroquine and chloroquine actually do have zinc ionophore activities. So it's really interesting. But quercetin—raw onion, red apples with the skin on, red grapes, your berries, green tea. 

Mark: Yes.

Elisa: Actually, EGCG from green tea was found to have zinc ionophore activity, too. Drink up your green tea. That's one great way. Green tea also has theanine which can help you feel calm and relaxed, which we all need during this time.

Vitamin C, in particular, there's been some interesting studies and there are some ongoing studies looking at vitamin C in the ICU. Vitamin C has been found to be protective against sepsis. There's one study looking at high-dose vitamin C. I mean it wasn't even what I would consider incredibly high-dose, but I think it was 24 grams in a 24-hour period found to be protective against sepsis. That's what people with COVID-19 are dying from.

Mark: As well as septic shock.

Elisa: Septic shock.

Mark: The vitamin C being used with dexamethasone has doubled the survival rate of septic shock in hospitals, and has now become very, very much mainstream that those doses of 10 to 20 grams therapeutically delivered. It's more like a drug. It's not like having your oranges in the morning, that's for sure. 

Elisa: That’s right.

Mark: It’s fascinating because there are a group of studies already being done in China with the use of that same intravenous vitamin C. We're yet to see the results, but it will be fascinating to see what effect, if any, it's had on the virus.

Elisa: Yeah, I mean, and what a simple intervention, right? That would be so cost-effective. 

Glutathione. I mean everyone listening to the podcast knows the importance of glutathione, but one thing that struck...you know, when you look at some of the studies around glutathione depletion with acetaminophen or paracetamol in viral infections, paracetamol does seem to prolong the duration of certain viral infections, and even the severity integration of shedding. 

When this whole concern around NSAID medications and worsening of COVID-19 came out, the recommendation was to use paracetamol. I actually took a step back and I thought, "Oh, my gosh. Now people are going to be chugging down the Tylenol. That would be one of the worst things they could do because of the depletion of glutathione." So I do have concerns around that.

With NSAIDs, I don't know. I'm not convinced that NSAIDs are necessarily a problem. We just don't have enough data around that. But the theory behind that was that NSAID medications can increase the level of ACE2 in your serum. 

Mark: Yeah.

Elisa: Now, what’s fascinating about that though is that ACE2, as a medication, by increasing serum ACE2 may actually be protective against sepsis. 

Mark: Yes.

Elisa: Theoretically if the serum ACE2 isn't blocking attachment of the SARS-CoV-2 virus to ACE2 receptors, it potentially could actually benefit SARS-CoV-2 infection. So I don't know. I mean that was the same concern raised with vitamin D and vitamin A, and maybe not taking vitamin D and vitamin A right now. But I have not been recommending stopping your vitamin D or vitamin A because of how important they are for our immune system functioning, and the fact that so many people are deficient or insufficient in vitamin D worldwide.

Mark: It does seem as though the COVID-2 infection is a two-stage infection. The fascinating thing that has been recommended is you don't want  immunosuppressants in the early stages of it when you want to build a vigorous immune response. A lot of people get to the point where they have effectively beaten the virus, and the viral titres are dropping and the PCO is going negative. And then the cytokine storm hits. As you would think as the virus is dropping away, the immune system would ease up a little bit but instead, for a smallish group of people, those especially with heart disease, diabetes, those with lung disease, it goes into a second kick.

It seems no one can figure out what's going on. The virus is dropping away. Why would the body not just back off? Why does it go into this cytokine storm and then need aggressive ventilation and immunosuppressants and all the rest of it? It seems to only happen in older people who've built up a kind of health debt for enough years. 

Elisa: Yeah.

Mark: There’s a little trapdoor that no one knows about it until it starts to happen. When it goes off, it goes off very vigorously and then you don't use immune stimulants. You use immune suppressants. No that's the medical way of “stimulate it, suppress it." Food seems to have all those capacities within them, so you get all of it in a package if you're not going for a goal, "I know better than the virus. I'll attack it with vitamin C," or, "I'll attack it with Plaquenil." It seems much safer to run back on to the early stage of the infection. To set the stage for a more settled recovery of the immune response, not fall into that cytokine storm.

I think that's where we're too smart for ourselves. We think, "Oh, we've got to increase the immune response. Or we've got to suppress the immune response," like there's one answer. Viruses are smart. They made us, effectively. We gave them a way of getting out. They know how we react. They don't care if we live or die at the end.

Elisa: Well and I think that understanding our immune response and our immune system, it's really, I think, created a reductionistic view of which cytokines are pro-inflammatory, which are anti-inflammatory, which are regulatory. Because we know IL-6, which is implicated in the cytokine storm, has both pro- and anti-inflammatory properties. 

Mark: Yeah.

Elisa: We can't just simply say, "Let's target IL-6." There are some studies looking at IL-6 monoclonal antibodies, but it's just not that simple. I mean to think that we could really understand exactly how each of these cytokines work and which ones need to be downregulated or upregulated is really too simplistic.

But I think bottom line, you know, with the cytokine storm, most people have to remember cytokine storm is rare. It happens with COVID-19 but it's still a rare phenomenon.

Mark: Right.

Elisa: And I think, if you're too afraid to take their vitamin D or maybe take their elderberry because, “Oh, my gosh, could it trigger a cytokine storm.” I really think that, when we are, as you said, sticking to food as medicine and then also taking a reasonable amount of supplements, not overdoing things, we can't trigger ourselves into cytokine storm. There are other things that are happening.

Mark: Right. It's always tempting to say what's the worst-case scenario. What I want to finish on is what's the best-case scenario of this? There will be suffering. There will be deaths. There will be severe disease. There will be trauma to families. The question of how we emerge from this. This is a traumatic event economically, socially, psychologically. There's so many areas that are all happening for the first time in my memory, I mean, I’ve been around 64 years. I don't remember anything quite like this. There's so much happening. Do you have a sense yet of how we emerge from it? Do we emerge wiser? Do we emerge scared? Do we just go after every bat in China and murder them all in their caves? What do you think the outcome will be? How is there a positive from the experience?

Elisa: I think that we all have a choice to make about what kind of an outcome we want for ourselves and for our communities and for the world. This has to be an active decision. We have to actively choose to make this an opportunity in the face of one of the greatest adversities that we will ever face. Some of us will not know tragedy like we will know in the coming months. 

But when we look to see… I was reading this one article that the greatest corporations in the world were founded during recessions. Disney was founded during the Recession. CNN. And even FedEx, I was reading, was founded in one of our recessions. It is in times of adversity and tragedy that we have a choice to either let that consume us or to really be reborn, and really be creative in how we want our world to look like, and how we want our life to be post-COVID-19.

This is where we really need to think creatively, think with our kids, think with our children. This is the time to really reflect on what our true priorities are. For our kids, this is a golden opportunity where, for the first time in their young lives, they will not have instant gratification. Because from the moment that they were born, this generation of children has known nothing but instant gratification. It is time for us now to sit back and reflect how are we going to live our lives, how do we want to show up for the world, what lasting memory do I want to leave upon this Earth, and how do I want to leave this in a better place. I do think we have that opportunity, if we take it.

Mark: It is an opportunity to pause, isn't it? Life, I think in America as well as Australia, most of the Western countries, rolls on with a kind of inability to pause, stop. There is nothing that gives us time to reflect and consider. It seems that, although the panic was the first response, there are now people who are taking the time to reconsider it and build something new, and pause, and not just simply be on the roundabout of, "We've got to get to work. We've got to get to work. We've got to pay the bills." All of that, we realise for the first time, hey, that's an option that we chose. 

Elisa: Yes.

Mark: The virus is an option that we may not have chosen but it forces us to stop and say, "Actually, is paying the rent that important compared to being alive next year, or next month, or next week?"

It does change priorities. I'm seeing this in my patients that the first week or two or this was all panic of, "Will I die?" The next time has been, "You know what?" I see chronic fatigue syndrome patients. "Now everyone knows what I feel like," they say. Locked away in your home, you can't go shopping. You can't go out jogging. All of those things, other people are getting a sense of it and being kinder to people who suffer it all the time.

Elisa: Yeah.

Mark: I think there's an opportunity with those ideas of the gratitude, and pause, and reflect for us to emerge better than when we went into it. For us to emerge with a better balance in life with a sense of what we can and cannot do, what's obligatory and what's optional. That's empowering some of my patients. So the upside for them is already happening. If everybody thinks you're just a loser because you're not on the rat race, then you are a loser. When everyone has to stop, they start to think, "Oh, maybe that's not what life was all about." I know Donald is worried that we might lose the plot and not be economically viable anymore, but the idea of valuing health, and wellness, and joy, and happiness, and the new values could just be one of the great upsides of this pandemic.

Elisa: Yes. In a way, it has to be. I see all of these memes on Instagram and Facebook and how people are working to really better themselves. My wish is that all of this sticks because, in times of crisis we can promise things for ourselves, but it's really when things get better, that's going to be the true test of can we really continue to make this a better world than what it was pre-COVID-19.

Mark: Dr Elisa Song, a paediatrician and my guru in the areas of health especially when it comes to anyone under 16 years of age, it's been delightful to talk with you. Thanks for your wisdom.

Elisa: Thank you, Dr Donohue. So excited to be back with FX Medicine and everyone down in Australia. My heart goes to you. I know we're just a little bit ahead of you but I'm sending all my love and gratitude to everyone down under.

Mark: And we will send it your way as well. It brings one world together. This is not the time that every country has its own little trauma. This is a time that we either come together or we run the risk of losing the plot. But I would encourage everyone to follow the outline that you've given us today especially when it comes to looking after family at home over the next months. So, thank you very much, Elisa. It's been delightful.

Elisa: You're welcome.




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