Twin epidemics of covid-19 and non-communicable diseaseBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2618 (Published 30 June 2020) Cite this as: BMJ 2020;369:m2618
All rapid responses
In their editorial the authors describe the similarities between COVID-19 and non-communicable diseases (NCD’s) and call both “socially transmitted conditions” . The authors mention important factors behind the pandemics of NCDs, such as poverty, poor education, inadequate housing and the influence of the tobacco, alcohol and processed food industries. However, the authors fail to define why these NCDs are socially transmitted conditions. We believe that a better understanding and recognition of the social contagiousness of unhealthy lifestyle behaviour is crucial to decrease the prevalence of these behaviours and the related NCD pandemics. People are not born to behave unhealthily, but learn to, how to and when to do it from others who already do it, including family members and peers. The social contagiousness of unhealthy behaviour is, however, known to go far beyond two directly connected friends or family members .
If smoking, drinking alcohol, and eating unhealthy food are indeed socially contagious and if we compare it to the spreading of infectious diseases like COVID-19, it is interesting to know what the ‘effective reproduction number’ (R) would be. The R is used to measure the spreading capacity of an infectious disease as COVID-19. It stands for the average number of individuals that one infected person will spread the virus to at a given time in a certain population. The level of R varies in time and can be influenced by measures, such as social distancing and isolating infected individuals. To reduce the NDC pandemics it could be important to express the transmission of these unhealthy behaviours in a transmission coefficient, such as R. It is known that within families the intergenerational transmission of these unhealthy behaviours is relatively large. For instance, children of smoking parents have a 2 to 3 times higher chance of becoming a smoker themselves. How would this translate in a transmission coefficient R?
During the past decades the number of smokers in The Netherlands has decreased very slowly. At this moment about 3 million people in our country smoke and about 27.000 teenagers start to smoke every year. On the back of an envelope, one could say that the national R for smoking in the Netherlands in the past years is about 0.009. This indicates that a transmission factor far lower than 1 is sufficient to keep the pandemic of smoking going. Most likely the transmission coefficient R varies between different social networks, subgroups of different socioeconomic status or between large city or rural areas. This observation would translate into another R of a specific unhealthy lifestyle factor in specific groups at a given time. Detailed knowledge of the landscape of transmission and specific effects of different unhealthy lifestyle behaviours in specific ecosystems or countries could be of great help to disrupt the transmission of unhealthy behaviour and stem the tide of pandemics like that of obesity, smoking, diabetes, and alcohol use.
1. Sheldon TA, Wright J. Twin epidemics of covid-19 and non-communicable disease. BMJ 2020; 369:m2618 doi: https://doi.org/10.1136/bmj.m2618
2. Christakis N, Fowler J. Connected. The amazing power of social networks and how they shape our lives. London: Harper Press: 2010.
Competing interests: No competing interests
The authors note that "covid-19 and NCDs share a common set of underlying risk factors, including deprivation, obesity, older age, and ethnicity" and highlight, " Non-communicable diseases (NCDs) such as obesity, diabetes, heart disease, stroke, cancer, chronic respiratory diseases, and mental health disorders". All those risk factors and diseases have a parameter in common: the secosteroid hormone D3 better known as the sunshine vitamin. Deficiency of D3, defined as sub-physiological ( 25(OH)D3 100 to 150 nmol/L ) is global. The risk factors listed above are all accompanied by either low D3 or low responsivity to D3. The list of NCDs are also known to be influenced by D3 status or mechanistically.
To this scientist, conditioned to seek causal explanations, the failure of medical researchers to follow up these glaringly obvious clues is astonishing. For a compendium of research papers organised by disease see: https://vitamindwiki.com/. There is no shortage of failed D3 RCTs for most of those diseases. But extensive cell/molecular studies (1000s pa) support important roles for D3 amongst the several hundred genes that 1,25(OH)D3 promotes. There lies a big clash. It seems likely that something is amiss with the RCTs. Indeed there is: dose. Most RCTs use doses approved as safe by their national D3 advisory panel, and those doses are too low to reach physiological 25(OH)D3. Dose-ranging studies are rarely used. But there is an abundance of observational evidence that physiological and higher doses are beneficial in a range of diseases, safely.https://www.preprints.org/manuscript/202005.0265/v1 This important review emphasises the role D3 plays in COVID and summarises the safety of higher doses of D3 that should be embraced by future RCTs.
An RCT however big that fails to attain physiological 25(OH)D3 is not only wasted resource but adds another nail in the D3 coffin, because an outcome of "no observed effect" then becomes accepted as indicating "no role for D3", despite abundant cell/molecular evidence to the contrary. My conclusion is that badly designed RCTs for D3 - and the vast majority are - are dangerous to health.
A single dose RCT is an abuse of science, no biologist would pass the most perfunctory referee with a dose-response curve with one point on it. But amongst RCTs one dose is commonplace and held up as the Gold Standard. Nonsense.
There is an alternative, and eventually this protocol that puts causation first and foremost will succeed, as it has with providing a causal role of D3 status in COVID: https://www.medrxiv.org/content/10.1101/2020.05.01.20087965v3
Seen from the viewpoint of D3 the authors' twin epidemics reduce to just one: the pandemic of D3 deficiency.
Competing interests: No competing interests