By Dr Yvonne Chuon, Lifestyle Medicine Physician
Kuala Lumpur
Image courtesy of www.economist.com
As late as last week, COVID-19 was a disaster happening elsewhere in the world - killing other people, changing other lives. With Malaysia rising through the ranks of COVID-19 inflicted countries -and the deaths of the first few infected Malaysians - it has grown to be a force we cannot take for granted.
This article started out of my own fears for my spouse - who works in the epicentre of treatment of COVID-19 patients in the Klang Valley, but quickly grew to include my thoughts on the things that I do to protect myself and my spouse, and how we should all protect ourselves - and actually make a difference in controlling the spread of the new pandemic.
(When i say protect, I confess that I believe that God is in control of everything (i.e. He protects me), but as a mere human I try to do my best with the blessing of knowledge and wisdom that He has given me.)
So how do I protect myself and my spouse?
It may not be breaking news, but it is solid advice to wash your hands with soap and water for 20-30 seconds to allow sufficient contact time. When in public, maintain a distance of 1-2 metres between you and others.
What about face masks? Wear a mask if you have respiratory symptoms - sneezing, coughing or a runny nose - or if you are looking after someone else who is sick. You need to learn to use a a mask properly. Once a mask gets moist, it is less effective and should be replaced.
Putting on a mask without full knowledge of when and how to wear it can be dangerous because it gives us a false sense of being safer than we really are. Also, when coughing, cough into your elbow - or into a tissue and throw it away. Spitting and leaving tendrils of mucus all over is revolting, but worse - leaves viruses lurking in wait for playful childish fingers.
On March 6, 2020 doctors in Sungai Buloh Hospital received the directive to transfer out nearly all their patients to make way for the conversion of the hospital to a state COVID-19 centre. A timely order - in the days that followed COVID-19 patients poured in, flooding newly prepared isolation wards and ICUs.
All in all, a good move from a public health point of view. On a personal level, it presented me with a predicament. My husband roams the clinics and wards of this COVID- Centre and comes home to me. How should I sterilise him when he comes home?
Alright - it is really not quite as dramatic as that. This is how a typical evening goes:
I open the door and let him in with a sweet smile (ok, maybe not everyday). I can’t kiss him as we consider him contaminated. He brings his work-bag to the utility room and gets ready to take a shower in the second bathroom.
Before he showers, knowing that a typical healthcare-provider (HCP) usually doesn’t get enough hydration at work, I hand him a glass of water and some fruit after he washes his hands.
I make him drop his clothes in a pail where I soak them in sodium bicarbonate (baking soda) for a few hours before washing them in the machine. After his bath, he sits down to a warm (and mostly whole food) meal with an occasional home made dessert.
Once he’s home, I can breathe a little easier- at least we are in a relatively safe and contained environment. I can’t say the same for when he’s at work.
HCPs that work directly with COVID-19 patients, especially those that are on life-support systems do use space-suit like HAZMAT protective gear. But many HCPs work in other sections of the hospital with patients who have not yet been labelled as COVID-19 positive. Most HCPs are not provided with free masks or hand sanitisers to carry around. When supplies are enough, clinics or hospitals have them available in clinic rooms and hospital wards, but in a pandemic - this is hardly enough.
So my advice to the general public would be to wear a mask if you are unwell- even if you are going to the hospital - to protect others around you from getting sick. Unfortunately, as not everyone behaves so responsibly, you may also need to wear the mask when you suspect people around may be sick - which is usually the case in a hospital. Personally, I only wore a face mask when I was unwell and my elderly parents were with me. That’s all on face masks, let’s move to to hand sanitisers.
Hand sanitisers are convenient especially since you can’t actually wash you hands all the time - in the lift, walking in the park, in the car, before and after opening or closing a doors in public places - so it made sense to me to do some research and start making my own alcohol-based hand sanitiser.
There are many hand sanitiser formulas out there, Although alcohol-based products are generally drying to the skin, the ideal sanitiser should be alcohol-based to provide optimum germicidal (germ killing) ability. I love natural and organic skin care items - I even create my own dermatologically tested skin care products to cater for my patients with eczema or dermatitis, and my own sensitive skin. But dry skin is an acceptable trade-off when you need to protect your life.
I prefer a gel-type hand sanitiser opposed to a spray (which dries too quickly) because it gives more contact time between the sanitiser and our skin, which increases its effectiveness. For those of you with sensitive skin like me, it may be more sustainable to use a moisturising hand-sanitiser. However, the addition of moisturising ingredients should not compromise the alcohol content.
So, realising the limitations of his employer, I equip my spouse with a small bottle of hand sanitiser to clean his hands.I do use the spray-type of hand-sanitiser too, but mainly for other antiseptic purposes. I have been called obsessive for it, but from the early days of my medical career, I have always sanitised my work-bag and personal items (phone, purse, stethoscope) when i got home from work. It has become a habit.
With so much talk on hand sanitisers, let me remind you- a 20-30sec hand wash is still the best way to keep germs at bay - hand sanitisers are mainly for when you don’t have access to running water and soap.
Image courtesy of Bruno Germany from Pixabay
We have discussed practical steps to limit the spread of COVID-19, but let’s talk about something equally important- a strategy to boost our immune systems - so that our bodies can fight off the infection if we do get exposed.
COVID19 is a rather new virus, so we don’t know that much about it. In some ways, it acts differently from more well-known influenza viruses (the cause of the flu), but in many ways, the way our bodies fight the two viruses are similar. So, strengthening your immune system against the influenza virus will also be beneficial in fighting COVID19. Also, catching a flu massively increases your risk of getting a second respiratory infection like COVID19, so it makes sense to prepare our bodies to fight infections in general.
The human immune system is monstrously complex -with intricate interdependent stages and pathways.Each level of our immune response requires specific micronutrients - something that scientists are still investigating. To date, there are only a few well researched micronutrients, and they happen to be mostly from plant-based foods.
So it is much healthier to pack your diet with properly cleaned fresh fruits and vegetables. Fruit and vegetable cleaning liquids are commercially available, but I personally wash mine with lots of running water and soak them in salt water before use.
The absolute worst thing you could do (food-wise) is to eat food with low nutritional value like fast food, processed food, refined carbohydrates and refined sugars - which is exactly what we saw people stuffing their shopping carts with in the panic-buying of the last few days.
As a part-time homemaker - as much as I can -I opt for whole foods as when preparing meals.
Whole food - not organic food.
The term “organic” is subjective and I don’t mind choosing an organic food item if it looks fresh and the price isn’t too much more than the so called “non-organic” items. In many cases, it is simply a marketing strategy and nothing more than that, so let’s be practical and not go overboard with our food purchases.
I generally choose unprocessed and unrefined foods - or those that are processed and refined as little as possible. My personal choices are legumes and nuts, eggs, vegetables, fruits and whole grains.
I advocate a balanced diet with adequate hydration. You have probably heard that 8 glasses of water a day is good enough, but in our hot Malaysian climate, 3 litres of water per day is more acceptable (unless you have been told by your doctor that you need to restrict your fluid intake due to a heart or kidney disease).
How much water your body needs really depends on your daily activities and other idiosyncrasies. As for me, from onset of the COVID-19 outbreak, I realised that I need almost 4-5 litres of water daily to avoid getting a throat irritation or an occasional headache. My husband and I have routinely started drinking almost 500-800ml of water from the time we wake up till breakfast.
Of course, this is only possible if you wake up early - and yes, our circadian rhythm plays a role in the peak performance of our immune system. We wake up early to meditate on God’s words, do body stretching, and, if time allows, we go for a short walk before our breakfast.
Malaysians especially tend to like to have breakfast out - at a coffee shop, cafe or stall. With COVID-19 hiding in every coffee shop, it’s much safer to eat at home. To ensure a home-made breakfast keeps us happy and satisfied, we try to have 3-4 different breakfast menus per week.
I usually pack a lunch/ snack for work. Examples of packed lunches/snacks are mixed nuts, vinaigrette salad, fruits or sandwiches. These are simple and easy to prepare beforehand. Packed foods are something I started when I was working full time, not just during COVID-19.
If you’ve read till this point, you’ll know that whatever I am saying is far from stellar - it’s just something sensible. Unfortunately, I find that not many practice these simple things - least of all our HCPs, which is strange because all of us learned in medical school that disease management starts with lifestyle modification (before it comes to the wonderful and powerful drugs and medicines we take for granted today).
Hippocrates - the Greek ‘father’ of medicine and doctors through the ages have treated uncountable people with diseases. History shows us that many of these treatments may have been misguided, which is not surprising since effective medicines were only mass produced since the early 1900s.
One thing that the ‘fathers and sons’ of medicine did get right, however are that many diseases are preventable - and even curable mainly through lifestyle changes. These lifestyle changes are my passion, and I could go on about them forever, but I’d better go straight to the main points or I may lose your attention soon.
Waking up early in the day is important, but make sure you are getting enough sleep. I would say sleep is even more important than food - but many of us prefer to stay up late (watching TV, surfing the internet, gaming, working or whatever) and keep ourselves awake by binge-eating.
Sleep is crucial to our immune system. A study done at UCSF found that people who sleep less than 6 hours per night have a higher risk of catching the common cold (which is also caused by a virus). Sleep is essential to every human being on earth - even more so HCPs who the public trusts with their lives.
HCPs are not anointed with super-powers to stay up the whole night resuscitating the dying, doing surgery and otherwise saving lives without draining their own life force. During a recent conversation with a friend, she jokingly said that HCPs don’t even have the privilege of a Spider-man or Batman suit/gadgets to protect themselves - they are just expected to fight like Jackie Chan, with their training and their wits.
In this vein, but wholly unrelated to sleep, during my 10 years working with the Ministry of Health, I myself was given an influenza vaccination only once. Truth be told, HCPs are unfortunately very poorly protected by Ministry of Health in terms of their physical and mental health.
My apologies for deviating from the topic of sleep. Sleep helps us to conserve energy for the repairing process our bodies need to prevent things (hormones included) from going haywire. More importantly, inadequate sleep reduces our immunity. I truly believe that the only reason why our HCPs survive without adequate sleep is because of protection from a higher power.
How much sleep we require is different for each individual, so you need to find out how much daily sleep you need. The bare minimum should be 6 hours. Try to aim for at least 7 hours every night if not more and take a 20 minute power nap if you notice that you are getting tired frequently during the day. I personally find that 8 hours of sleep is good for me - when i sleep early, I constantly wake up 8 hours later feeling refreshed without an alarm clock.
Changing your sleep habits will not be easy, I know because prior to my current 8-hour sleep routine, I went through a nearly 20 year span where I slept very little for various reasons — my studies, scholarship demands, exams, being on call and peer pressure - and, let’s be honest sometimes just to watch movies or play games.
I was a real night owl, drinking gallons of green tea and devouring bars of chocolate while savouring my medical notes deep into the dark of night. Why green tea and not coffee? I enjoy coffee, but during my first year of medical school, I drank seven cups of coffee the night before an important exam and still couldn’t keep myself awake - coffee does not have the usual effect on me. So I started to rely on God and my own desire to stay up night. Nowadays, if I know that i need to stay up late, i just will.
Image courtesy of iStock
I would consider movements and physical activity separately as they are not really the same thing. If you find yourself sitting down most of the time at work or otherwise, I suggest that you get up and move around every 30-45 minutes. Sitting too long is a chronic problem among office workers, but also among clinic doctors and some nurses.
I don’t mean to judge anyone - the circumstances put them into sedentary lifestyles. Imagine seeing more than 100 patients a day with mostly chronic diseases (Diabetes mellitus, hypertension and cardiovascular diseases). For a doctor to see them all - to ensure their diseases are being treated well and are not developing threatening complications - on an 8-5 schedule, he or she of course has to sit at a desk without even going to the toilet for up to 9 hours.
So, my dear colleagues in clinics - especially government clinics when the taxpayers demand every second of your attention - please love yourself a little, get up and walk around every 45minutes, use the washroom if you need to. No one is going to pay your medical bills when you get a urinary tract infection. Also, take time to hydrate yourself, ideally with plain water, and not iced coffee to keep you alert.
My mantra for physical activity is moderation. Exercise should not be too intense or too mild. Research shows that people who exercise in moderation report fewer colds. Regular and consistent exercise leads to substantial long term benefits to our immune system.
Research shows that immune cells circulate through the body quicker during moderate exercise, and thus more efficiently kill bacteria and viruses. Of course, evidence shows that too intense exercise can negatively impact your immune system - more than 90 minutes of high intensity exercise can leave athletes more susceptible to illness for up to 72 hours after the exercise session.
At the right level, exercise can be an immune booster, but do not sacrifice sleep to exercise. My spouse and I love to take a brisk walk and an occasional run in the park nearby. We also cycle twice a week - what started as a 15 minute session a few months ago now usually lasts 45minutes to 1 hour. We also recently started doing 10 minutes of stretching indoors and we find it to be calming and relaxing.
I believe in baby steps and doing something that you enjoy - it’s the only way to be consistent. If you don’t enjoy doing something, there’s no way it will become a part of your life, so explore your options thoroughly. For a beginner, aim at moderate exercise - 15 minutes per day, at least 5 days a week.
Planning to exercise daily is actually better because you don’t need to struggle deciding which days you will exercise - if you waste all your mental energy planning your exercise, you may find that you don’t have enough physical energy to actually exercise.
One of the most common questions a doctor receives is “What should I be eating to make my condition better?”. In most cases, the question quickly unfolds to include supplements. As we have seen prior, healing is something that starts with changes to our lifestyle, and not by ‘taking a pill for every ill’.
However, we have talked about micronutrients and our immune system and there definitely is a role for immune system boosting supplements in COVID-19 times, so let’s look at them.
First and foremost - Vitamin D. We have the most solid research on the role of this micronutrient in the prevention of viral illness. People with higher Vitamin D levels have a lower risk of upper respiratory tract infections or colds. Ideally, you should get your Vitamin D level checked, though that is not the main idea of this article.
Our bodies produce a lot of Vitamin D through light sun exposure.(NOTE: Light to moderate sun exposure.EXCESSIVE sun exposure is harmful!) For social and comfort reasons, most people in our society avoid the heat of the sun and some almost religiously use sunscreen, which means we hardly make enough Vitamin D in our body. During this pandemic, with many people staying indoors as much as they can, I would advise supplementing your diet with 1000IU per day of Vitamin D to optimise your immunity and help prevent infections.
Next, and perhaps most popular of all - Vitamin C. A large Cochrane review (which is a study that studies many other studies) analysed 29 separate clinical trials with over 11000 research participants and found that supplementing with Vitamin C can help shorten the duration of the common cold (by almost 10% in adults, and nearly 20% in children) and make it less severe.
One study showed that intense athletes who take 0.6 grams to 1 grams of vitamin C cut their risk of getting sick in half, so it’s very reasonable for us to supplement our diets with 1-2 grams of Vitamin C per day.
Walk into any pharmacy (wear a mask and sanitise your hands after opening the door) and you’ll see that many Vitamin C supplements come with added zinc. That’s not just for fun. Researchers agree that zinc supplementation helps reduce the risk of pneumonia (lung infection) and the common cold - especially in children and the elderly.
Zinc also shortens cold durations by about 30% if it is taken before you start to have symptoms, or at least within 24 hours of starting to have symptoms. My recommendation is to take 20grams of Zinc daily.
Add garlic to your diet, Garlic is known to have antiviral properties and is shown to improve immune system function. A randomised controlled trial (that means garlic was compared to a placebo) showed that supplementing diet with 100mg of garlic concentrate daily for 12 weeks reduced the intensity of cold symptoms and shortened its duration.
You can buy garlic supplements from a pharmacy, but I try my best to add garlic in my meals whenever possible. With the restricted movement order coming into action today, perhaps you can have some fun experimenting with simple recipes at home (My husband and I enjoy garlic in stir-fry vegetables and home-made hummus) to reduce the amount of pills that you swallow every day. Cutting garlic into smaller pieces makes it easier on our tongues - but that comes down to personal taste.
A recent meta-analysis (another type of study that analyses hundreds of other studies) revealed that supplementing Flavonoids reduces upper respiratory tract infections by 33%. It was also found to decrease the sick day count by 40%. Good sources of Flavonoids are green tea, blueberries, cabbage, dark chocolate (not milk chocolate) and cocoa, onions and strawberries.
My husband and I are taking these few supplements especially during this pandemic season - Probiotics can also be helpful. As much as we can, we try to get the micronutrients we need from our meals as to be honest, popping pills into our gut is not something we particularly enjoy.
We’ve come to the end of this list of my thoughts on the COVID-19 pandemic. If you’ve followed my article so far, you’ll be terrified to know that a pandemic is an infection outbreak that spreads to multiple continents - in the case of COVID-19, nearly worldwide.
Rapidly spreading infectious diseases are as old as civilisation itself - the Biblical plagues of Egypt, leprosy, the Black Death of Europe, the White Death of Tuberculosis, and within living memory, the Spanish flu, SARS and H1N1 come to mind.
Our world today is better equipped then at any time in history to survive a pandemic infection. Social media allows us to work and meet virtually, meaning life can go own despite physical isolation. Useful information can be spread to the masses almost instantly. Medical care continually grows and advanced life-support is readily available.
As you read this, there are scientists working at studying the COVID-19 virus and trying to develop vaccines and drugs to fight it better. Yet, my dear Malaysians, for all the advances science has given us today, we ourselves as human beings are not very different from our ancestors who survived the plagues of old.
The same public health issues that doomed half the people of Europe to the Black Death in the 1300s still plague us today. Panic, crowding, a lack of attention to hygiene -simple things that you and I can change for ourselves.
So, please protect yourself and your family. Avoid crowded places unless you have no choice. Keep good hygiene, eat whole food (less processed food) drink at least 3 litres of water if not more, have adequate sleep, move regularly and start exercising today. And keep your faith in the higher power who is in control of everything - from the mountains and the oceans, to something as invisible as the Coronavirus.
It is in times like this - when a particle our eyes cannot see can bring our world as we know it to its knees - it is then when we see the breadth and depth of our reliance on God. In some of our eyes, perhaps it is unfair and unjust. It seems so to me sometimes. Then my eyes search out a line from one of my favourite books.
“Where were you when I laid the earth’s foundation? Tell me if you understand. Who marked off its dimensions? Surely you know.” And while you and I both know we were not there when the foundations were laid, in our heart of hearts we know who laid them. Let’s trust in that.
Godspeed, my sisters and brothers. Let’s make a difference today.
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