The Minority Report

 

Within the statistics on coronavirus (SARS-CoV-2) and Covid-19 lies a disturbing truth – people from black, Asian and minority ethnic (BAME) backgrounds are more likely to die.

As concern is sparked your first response might be – why is this even so? But if you are from this background your next thought might be – what can I do about it? Early data from the UK and USA tell a similar story: the risks are greater for those of BAME heritage [1] [2]. While prevalent social and economic issues appear to contribute significantly to this increased risk, certain health factors do too. Where do these health risks come from? How can you overcome them, support your immune system and strengthen health and vitality? If vitamin D is one of the answers, but your levels are low, why is it impossible to eat your way out of a deficiency? Solutions lie within Nutritional Therapy which offers a glimmer of hope. Risks from Covid-19 might be higher if you are from a BAME background, but there is the potential to do something about it, starting from today.

 

Find your BONUS MATERIAL at the end of the page!

 

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THE MINORITY REPORT

Nina Sabat BscHons DipNT Registered Nutritional Therapist

 

THE HIGHER RISK POSED BY COVID-19 IN BAME POPULATIONS

A greater incidence of death

According to recent data, people from BAME backgrounds are more likely to be hospitalised with Covid-19, and more likely to die compared with the Caucasian population [1]. While only accounting for 14% of the England and Wales population, 34% of Covid-19 patients in intensive care come from BAME groups [3]. A report by the Institute of Fiscal Studies (IFS) thinktank gained much attention in the press. They recorded a 3.5 times higher record of death in British black Africans, deaths which were 2.7 times higher in British Pakistanis, and a 1.7 times higher incidence of death in Britons from a black Caribbean background. These numbers remained significantly higher, even when sex, age and geography were accounted for. However, as co-author Ross Warwick clearly explained: “There is unlikely to be a single explanation here and different factors may be more important for different groups.” [1]

In America, the numbers are similar. For example, more than half of Covid-19 related deaths in Chicago were among African Americans, despite them making up less than a third of the city’s population [2]. 

Despite following current guidance of social distancing, frequent handwashing and wearing masks appropriately as a nation, the balance of risk is clearly not favourable for those from BAME backgrounds [4]. 

 

Understanding where the health risks lie

In the UK there are trends within various BAME populations which increase risk of exposure to the virus – a higher chance of working in key worker roles; a greater probability of working in healthcare; an inability to work from home. Along with this are other factors which could increase transmission – a greater likelihood of living in densely populated areas; or living with extended family in one home. Finally, there are other ongoing health conditions which have been linked to increased Covid-19 risk and severity – obesity, type 2 diabetes and hypertension all of which affect greater numbers of people within BAME communities. 

In the UK, the rate of obesity is highest in black African/Caribbean populations.

Risk of diabetes increases from the age of 25 if you are of African/Caribbean, black African, Chinese or South Asian heritage. In contrast, in other populations risk only increases from the age of 40 [5].

There is one more factor to add to this list, which is important for EVERYONE within BAME populations. 

It is the connection between vitamin D, which has a role in regulating immune function and reducing risk of respiratory disease, and the BAME people who live in the UK, who struggle to achieve and maintain healthy levels of vitamin D.

 

Failing the vitamin D test

You probably know of vitamin D as the ‘sunshine’ vitamin, as you make it in your body when sunlight hits your skin. Practically every cell has receptors to catch the active vitamin as it circulates in your blood, and it has a significant role in how your immune system functions. White blood cells which meet infectious agents increase circulating levels of active vitamin D. This encourages the production of proteins that can target the infection and destroy it. Vitamin D also quietens down the inflammatory molecules that accidentally cause lung damage in respiratory infections.

 An important vitamin indeed. However, there are several reasons why people of BAME heritage may never make enough, despite being exposed to Summer sunshine.

1. The latitude of the UK (its distance from the equator) limits the months you can make vitamin D from the sun – from April to August.
2. For UVB rays to pass the ozone layer and reach your skin, the sun has to be at the right angle – typically it reaches this from between 11am at the earliest and 4pm at the latest.
3. To make vitamin D your skin must be exposed directly to the sun – the rays can not pass through glass, plexiglass, perspex, sun protection or clothing. Air pollution and clouds also reduce the percentage of rays that reach the earth.
4. Age has an effect – the older your skin, the less vitamin D it makes, around 3 times less than when skin is younger.
5. Pigmentation has an impact too – the darker your skin the less vitamin D you make. You may be shocked by the difference. In one test, adults with different skin types were exposed to equal amounts of UVB radiation. In the time it took adults with white skin to gain a 30 fold increase in their blood vitamin D, the adults with black skin had no increase. They needed exposure to 5 times stronger UVB light to raise their blood vitamin D by a factor of 15, just half the amount [6].

There you have it, the many challenges to making enough vitamin D.

6. In addition, vitamin D status drops as BMI increases. As a fat-soluble molecule, vitamin D can become trapped in adipose tissue. This means that as weight increases there is less available to circulate in the body. Obesity rates in the UK are highest in individuals of black African/Carribean heritage.

If you live in the UK, there are 5 ideal months and a 5 hour window each day to make the most of them. You must be outside, you must bare some skin, hopefully you are outside on a cloudless, unpolluted sunny day. The older you are the less vitamin D you make, and if you have more pigmented skin you will make even less. If you also have obesity or excess weight, there is even less available to use.

Consider this study on 51 South Asians in the UK. At the start of the trial their vitamin D levels were insufficient. In fact, 45 of the group had levels less than 10 ng/mL, and around 18 of them scraped in with levels under 5 ng/mL. Just so you know, these are the levels when bone degeneration and malformations start to occur. By the end of the study levels had risen, by roughly 9 ng/mL to around 15 ng/mL. Better, but still insufficient. To achieve just this, this group needed to expose arms and legs for 45 minutes, 3 times a week for 6 weeks, to the same strength of light seen in Manchester at noon on a sunny Summer’s day [7].

 

The risks of playing a waiting game

A vaccine may be produced in the next 3 to 12 months, but is it worth waiting to see how things develop?

In the past, in temperate zones in the Northern hemisphere, just where the UK falls, there is a particular pattern to outbreaks of influenza type viruses. Cases rise from October, peak in January, before dying out by April’s end. One theory is that this seasonal response could be affected by fluctuations in vitamin D levels. In this pandemic, countries at the end of their Summer such as New Zealand and Australia have fared better – 4 deaths/million in both populations, compared to 511/million in the UK [8]. If coronavirus reemerges in Autumn as predicted, it will no doubt follow the familiar pattern.

If there is a causal link, the risks are too high to sit at home and hope for the best. For a BAME population who are chronically deficient in vitamin D, it makes much more sense to seize the opportunity and take steps to increase levels to a much healthier range.

 

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POTENTIAL NUTRITIONAL SOLUTIONS

You can not ‘eat your way out of’ a vitamin D deficiency

With the idea that many foods are rich in vitamin D, thoughts may turn to the diet. However, it is incredibly hard to eat your way out of a deficiency.

Public Health England suggest adults supplement 400IU (10mcg) each day all year round [9 ]. You may think the RDA of 800 – 1000IU (20 – 25mcg) is preferable. Others may prefer supplements of 1000 – 3000IU (25 – 75mcg) which studies indicate maintain good blood levels.

What would you need to eat to have 800IU of vitamin D in your diet? 

Start with 2 large boiled eggs for breakfast = 87IU. A mid-day cappuccino = 2.4IU. A 100g serving of herring for lunch = 216IU. More fish for dinner, this time an 85g serving of farmed salmon = 447IU. Add a shitake mushroom sauce = 20.2IU. 

At 772IU you are almost there.

For anyone vegan, or eating a plant-based diet, simply base ALL your meals around mushrooms, fortified milks and fruit juice.

As you can clearly see, none of these foods are suitable to eat, each and every day, which means plans to obtain enough vitamin D from your diet are unlikely to meet with success.

If you are eating a varied and sensible diet, the type of diet I would recommend as a Nutritional Therapist, you will not be able to ‘eat your way out of’ a vitamin D deficiency.

 

Selecting the ideal vitamin D supplement

Summer sunshine is sporadic, the amount of vitamin D made is limited if you have darker or older skin, and dietary choices are insufficient. This leaves supplementation as the only way for anyone from BAME populations currently living in the UK to have sufficient levels of vitamin D.

Here are 4 recommendations.

1. If you live in the UK, have brown or black skin, wear fully concealing clothes, avoid the sun, are older or housebound, or have obesity, assume you have a deficiency.
2. Choose a supplement of vitamin D3 rather than D2, as this from of the vitamin is typically more effective at improving vitamin D status.
3. Look for a higher strength supplement that delivers between 1000 – 5000IU per daily serving. This gives more flexibility when choosing what you need: a higher dose for at least 6 – 8 weeks to correct a deficiency, lower doses to maintain levels once they are in a healthy range.
4. Check the ingredients for fillers, binders, sugars, synthetic colours, and avoid the brands that have them on their list.

 

The magic of magnesium

In addition to vitamin D, there could also be a place for magnesium on your supplement list. 

In their recent review, Uwitonze and Razzaque (2018) highlight magnesium’s significant role, not only in how vitamin D is made but also how it is used by the body [10]. You need enough magnesium for the inactive pre-vitamin D made in the skin, to be activated in a 2-step process in the liver and kidneys. As for how you can use it, when magnesium levels are low, vitamin D is less effective clinically. Also, you miss out on giving your immune system some extra support, if there is not enough magnesium to influence metabolites of vitamin D. 

Magnesium is often referred to as ‘nature’s tranquilliser’, it is the mineral that helps your body process stress and manage anxiety. Unsurprisingly, your body would have dug deep into your magnesium stores in the last few months, to help you cope with recent challenges as they unfold. You might not have been able to replenish your levels, if your shopping and eating patterns have changed in the last few weeks. 

Foods high in magnesium include almonds, beans, broccoli, cashews, egg yolk, flaxseed, green vegetables, milk, mushroom, sesame seeds, fermented tofu and whole grains. Eating them regularly will help you top up. 

However if your appetite or diet is limited, a supplement may be needed to reach the 310 – 420mg that adults are recommended to have each day. Suggested dose varies according to age and gender [11].

 

Selecting the ideal magnesium supplement

Here are 4 recommendations.

1. Before you supplement, start by including as many magnesium-rich foods in your diet as possible, and eat them every day.
2. Look for a form which is well absorbed like magnesium citrate, magnesium glycinate, or a food-sourced product.
3. If magnesium upsets your stomach or gives you loose stools, try taking half the dose, or swap to a product that can be applied directly to the skin.
4. Check the ingredients for fillers, binders, sugars or synthetic colours and avoid the brands that have them on their list.

 

Conclusion

Current data indicates obesity and type 2 diabetes affect outcomes after exposure to coronavirus, and vitamin D deficiency potentially may increase vulnerability. Incidence of obesity, type 2 diabetes and vitamin D deficiency is very high in BAME populations. To date, these populations have been disproportionately affected by Covid-19, and have a higher incidence of poor outcomes and death. 

However, these three factors can be affected by diet and lifestyle choices. Simply put, this means each person has the power and potential to impact their everyday health. By targeting vitamin deficiencies and rebalancing a disturbed metabolism, it is possible to support the immune system and general health.

The potential solutions fall within Nutritional Therapy, where changes to the foods you eat, the nutrients you supplement and the new habits you introduce result in focused improvements to health. If you are in a BAME population, with increased risks from Covid-19, and are wondering what to do next, this is where I encourage you to start.

References

1. Siddique H (2020) British BAME Covid-19 death rate ‘more than twice that of whites’. The Guardian. Published 1 May 2020. https://www.theguardian.com/world/2020/may/01/british-bame-covid-19-death-rate-more-than-twice-that-of-whites
2. Yancy C (2020) COVID-19 and African Americans. JAMA Published online 15 April 2020. DOI:10.1001/jama.2020.6548
3. Intensive Care National Audit Research Centre (2020) ICNARC report on COVID-19 in critical care. Published 17 April 2020. https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports
4. Bhala N, Curry G, Martineau A, Agyemang C, Bhopal R (2020) Sharpening the global focus on ethnicity and race in the time of COVID-19. The Lancet. Published 8 May 2020. https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)31102-8.pdf
5. Diabetes UK (2020 ) Diabetes Risk Factors. Accessed 17 May 2020. https://www.diabetes.org.uk/preventing-type-2-diabetes/diabetes-risk-factors
6. Wacker M & Holick M (2013) Sunlight and Vitamin D: A global perspective for health. Dermato-endocrinology, 5(1), 51–108. 
7. Farrar M, Webb A, Kift R, Durkin M, Allan D, Herbert A, Berry J, Rhodes L (2013) Efficacy of a dose range of simulated sunlight exposures in raising vitamin D status in South Asian adults: implications for targeted guidance on sun exposure. American Journal of Clinical Nutrition 97(6):1210-6. 
8. Worldometers (2020) Coronavirus. Accessed 17 May 2020 https://www.worldometers.info/coronavirus/
9. Public Health England (2016) Scientific Advisory Committee on Nutrition (SACN) Vitamin D and Health Report. Accessed 17 May 2020. https://www.gov.uk/government/publications/sacn-vitamin-d-and-health-report
10. Uwitonze A & Razzaque M (2018) Role of Magnesium in Vitamin D Activation and Function. The Journal of the American Osteopathic Association, 118: 181-189. 
11. National Institutes of Health (2020) Magnesium https://ods.od.nih.gov/factsheets/Magnesium-HealthProfessional/

 

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Next steps

If you are of BAME heritage, live in the UK, and are concerned about your vitamin status, an appropriate plan would include a good quality supplement to address potentially low vitamin D levels. There could also be a place for magnesium on your supplement list, to support the production and action of  vitamin D.

As for addressing obesity or type 2 diabetes, there is no magic pill to transport you to your goal. However, while a nutritionally-based, personalised approach could take you closer, improved carbohydrate management could be the most practical first step to take at home. Whether focused on obesity or type 2 diabetes, your aim is to encourage improved metabolic function, by controlling your insulin and blood glucose levels. I would like to recommend a way to do this through your diet, by following ‘The Rule of 4’. This is my really simple way to fill your plate with the best types of foods to help you reach your goals. I promise to take an in-depth look at ‘The Rule of 4’ very soon, as it is a significant step to help you master your carbohydrate control.

 

Bonus material

I’ve created 2 special resources for you to download and keep or share with others.
Click here for your 11-POINT SUMMARY

Click here for VITAMIN D and MAGNESIUM SUPPLEMENT SUGGESTIONS

Coming soon THE ‘RULE OF 4’, A SIGNIFICANT STEP TO MASTERING YOUR CARBOHYDRATE CONTROL