Cabbage and fermented vegetables: From death rate heterogeneity in countries to candidates for mitigation strategies of severe COVID-19

ARIA group, Jean Bousquet*, Josep M. Anto, Wienczyslawa Czarlewski, Tari Haahtela, Susana C. Fonseca, Guido Iaccarino, Hubert Blain, Alain Vidal, Aziz Sheikh, Cezmi A. Akdis, Torsten Zuberbier, Amir Hamzah Abdul Latiff, Baharudin Abdullah, Werner Aberer, Nancy Abusada, Ian Adcock, Alejandro Afani, Ioana Agache, Xenofon AggelidisJenifer Agustin, Mübeccel Akdis, Mona Al-Ahmad, Abou Al-Zahab Bassam, Hussam Alburdan, Oscar Aldrey-Palacios, Emilio Alvarez Cuesta, Hiba Alwan Salman, Ashraf Alzaabi, Salma Amade, Gene Ambrocio, Rosana Angles, Isabella Annesi-Maesano, Ignacio J. Ansotegui, Paula Ara Bardajo, Stefania Arasi, Hasan Arshad, Maria Cristina Artesani, Estrella Asayag, Francesca Avolio, Khuzama Azhari, Claus Bachert, Diego Bagnasco, Ilaria Baiardini, Nissera Bajrović, Petros Bakakos, Sergio Bakeyala Mongono, Christine Balotro-Torres, Sergio Barba, Thomas Eiwegger, Rudolf Valenta

*Corresponding author for this work

Research output: Journal article (peer-reviewed)Review article

82 Citations (Scopus)


Large differences in COVID-19 death rates exist between countries and between regions of the same country. Some very low death rate countries such as Eastern Asia, Central Europe, or the Balkans have a common feature of eating large quantities of fermented foods. Although biases exist when examining ecological studies, fermented vegetables or cabbage have been associated with low death rates in European countries. SARS-CoV-2 binds to its receptor, the angiotensin-converting enzyme 2 (ACE2). As a result of SARS-CoV-2 binding, ACE2 downregulation enhances the angiotensin II receptor type 1 (AT1R) axis associated with oxidative stress. This leads to insulin resistance as well as lung and endothelial damage, two severe outcomes of COVID-19. The nuclear factor (erythroid-derived 2)-like 2 (Nrf2) is the most potent antioxidant in humans and can block in particular the AT1R axis. Cabbage contains precursors of sulforaphane, the most active natural activator of Nrf2. Fermented vegetables contain many lactobacilli, which are also potent Nrf2 activators. Three examples are: kimchi in Korea, westernized foods, and the slum paradox. It is proposed that fermented cabbage is a proof-of-concept of dietary manipulations that may enhance Nrf2-associated antioxidant effects, helpful in mitigating COVID-19 severity.

Original languageEnglish
Pages (from-to)735-750
Number of pages16
JournalAllergy: European Journal of Allergy and Clinical Immunology
Issue number3
Publication statusPublished - Mar 2021
Externally publishedYes


  • angiotensin-converting enzyme 2
  • cabbage
  • COVID-19
  • diet
  • fermented vegetable
  • kimchi
  • Lactobacillus
  • sulforaphane

ASJC Scopus subject areas

  • Immunology and Allergy
  • Immunology


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