Supporting patients with advice during COVID-19 recovery

Information on first-line and advanced dietary advice for professionals

Consensus statements from expert panels

  • Healthcare professionals should provide simple, practical, realistic and tailored advice for patients and use outcome measures to assess nutritional and dietary concerns, needs and other known conditions (regardless of diagnosis, care setting used, etc.)
  • Healthcare professionals should offer consistent and coherent advice.
  • Healthcare and social care professionals should advocate for patient care and referral where appropriate.
  • Healthcare professionals should discuss decision-making about nutrition as part of a multi-disciplinary team where possible.
  • It is important to include patients’ cultural and religious preferences as part of comprehensive and practical advice.

 

First-line dietary advice

What initial actions can a non-dietitian (nurses, GPs, or any other allied health professional) advise?

This section is focused on providing basic steps to prevent and/or tackle malnutrition as well as to address the most troublesome nutrition-related symptoms. Food first principle, which means addressing all nutritional needs through the use of food exclusively (1, 2).

  • A flexible mix of approaches would be required (3).
  • Use questions to determine suitability of dietary approaches or referral needs. For instance if they have underlying or related concerns:
      – identifying poor nutrition and offer to add nutritional value to their current diets
      – address long term issues that could have been neglected.
  • Offer simple practical and realistic advice for symptoms appropriate for each patient (see rehabilitation parameters), particularly respiratory, GI.
  • Give consistent written or online information. Offer suggestions for meals and snacks, and troublesome symptoms (3).
  • Need to ensure that information given is suitable to individual patient need – culture, reading/writing, braille.


Diet fortification

  • For patients with chronic obstructive pulmonary disease and nutritionally at risk, fortifying diet with milk powder, resulted in outcome improvements (4).
  • If a patient needs support to fortify their diet, over the counter nutritional supplements can provide convenient presentations for patients to access supplements when required (3). See Importance of achieving adequate micronutrients levels within the Advanced dietary advice section below for further information.


Use of Oral Nutritional Supplements (ONS)

Refer to your local guidance for ONS (this should be available through your prescribing support dietitians or medicines management team – your pharmacist may be able to support to find the right guidance). If guidance is unavailable, the following steps may be useful:

Step 1

Assess the patient using nutritional assessment (refer to local guidance for the assessment malnutrition if available). Consider the causes for any nutritional issues (go to nutritional assessment).


Step 2

  • Encourage the patient with food first approaches – please see the Food first tips for eating more or eating differently on this page.
  • In particular, encourage fortified drinks (see recipes in the diet fortification section) before considering ONS, because home-made food and drinks are cheaper and can be adapted to the patients taste preferences more easily. Refer to above bullet points in section.
  • Establish appropriate goals with the patient.
  • Follow your local guidance for dietetic referral as required.
  • Only consider ONS if the patient is at risk of malnutrition and is unable to meet their nutritional requirements through food and nutritious fluids alone. Refer to local criteria and guidance for ONS options. In the absence of local guidance the BNF provides a list on nutritional composition and brand.
      – ONS should generally be used on a short term basis, ONS are rarely required for more than three months.
      – The BDA provides a food fact sheet for malnutrition [PDF].
      – Another resource to encourage food fortifiers and snacks that are a source of protein [PDF] is provided by the Older Adults Specialist Group from the BDA.
      – The BDA Older Adult Specialist Group developed fortified drinks recipes [PDF] anyone can make at home.


Step 3

Once therapy with ONS has been started, it is crucial to review progress to avoid unintended complications such as excess weight gain. Nutritional status and nutritional goals should be monitored at regular intervals. Find out more in our Monitoring patients during their COVID-19 recovery section.


Step 4

If there is no improvement in the patient’s nutritional status, seek advice from a registered dietitian.

Food first tips for eating more or eating differently

The following are questions that, according to our expert panel, should be asked during consultations to patients to make decisions on how to advise them:

Aspects linked to nutrition and diet:

  • Food accessibility. Assessment of living situation. Do patients have appropriate support for their nutritional care?
  • Is the patient currently using nutritional supplements or other specific dietary-related products?


The following are reliable sources that provide ideas and tips to manage diet according to some COVID-19 symptoms. This can also be useful to plan meals and recipes for all kinds of situations (people who cannot cook, will not cook, or do not know how to)


NHS Wales (5) provides a website offering practical suggestions for patients who are recovering from COVID-19 on the following:

  • eating and drinking well, and how to increase interest in food
  • weight loss
  • fatigue management
  • shortness of breath (also consider consult with HCP if using inhalers and oxygen therapy would be recommended)
  • leaflets for patients with COPD
  • cough
  • dry/sore mouth
  • taste changes
  • sleep issues
  • psychological wellbeing
  • moving and exercise.


Available guidelines:  (3)

National Institute for Health and Care Excellence (NICE)

Emerging evidence

Inflammation and histamine

The British Dietetic Association (BDA) released a statement – Low histamine diets and Long Covid [PDF] – in the first term of 2021 after growing lay reports of people using a low histamine or similar types of diets. 

They documented the following:

  • When histamine in the body is high to support and defend our bodies against infections such as COVID-19, this can cause a wide range of symptoms including bloating, diarrhoea, nausea, headache, rhinitis, wheezing, hypotension, arrhythmia, urticaria, itching, flushing and fatigue. 
  • There is however a lack of consensus on foods high in histamine content and a lack of evidence on whether this approach works for patients with long COVID.
  • Anyone interested in trialling this for less than four weeks, should seek dietetic support to minimise any associated risks.

For more information, you can watch Professor Philip Calder's talk Is there an anti-inflammatory diet? on our Nutrition and COVID-19 Recovery page.

See also our Supporting COVID-19 recovery: operational challenges page for further information.


Vitamin and mineral supplements

To date, it is unknown if over the counter vitamins and supplements in general are helpful, harmful, or have no effect in treatment of ongoing symptoms of COVID-19 (3, 6).

For other chronic health conditions similar to long COVID-19 and/or for people with underlying conditions affecting vitamin intake, supplements are recommended only when food fortification or food only are not sufficient for the person’s requirements, which should be assessed by a dietitian or appropriately trained healthcare professional. (7, 8)

Vitamin D plays a role in preventing COVID-19 and treating patients in the acute phase. For long term consequences of COVID-19 this can be helpful particularly when living in an environment with lack of sun or during UK winter (10 micrograms or 400 International units) per day between October and March (8). More than this can weaken bones and harm kidneys. Obtaining advice from healthcare professionals is vital (9).

If you think your patient needs assistance in fortifying their diet, discuss this with a dietitian.

Using the Patients Association nutrition checklist

We encourage you to use the Patients Association nutrition checklist and functional measures (see list below) to avoid reliance on body weight as the criteria for instigating/ changing/ amending nutritional therapies/ strategies/ care plans if access to GP surgeries for screening is limited to more urgent care (and patients may not have scales available). 

See the Malnutrition Task Force website for healthcare professionals and the Patient's Association website information about this tool’s update

If it is possible to weigh patients, screen for malnutrition risk using the ‘MUST’ to monitor patients (10).

Potential outcome measures (11):

  • Functional such as the sit to stand test (e.g. patient feeling stronger)
  • Self-reported activity of daily living (e.g. resume normal hobbies, improve stamina)
  • Patient’s report of progress towards agreed goals (e.g. achieve functional independence)
  • Compliance with dietary advice (e.g. achieve desirable body weight)
  • Body weight through subjective observations (e.g. gain muscle mass)  or hand grip strength

Access a library available for NHS staff to perform some of these tests (NHS Digital)

Advanced dietary advice

Energy, micro and macronutrients

The European Society for Clinical Nutrition and Metabolism (ESPEN) published some guidelines (12) on energy, macronutrient and micronutrient distribution.

Energy requirements (12, 13)

  • 27 kcal/kg/day for polymorbid patients aged >65 years.
  • 30 kcal/kg/day for severely underweight polymorbid patients; lookout for refeeding syndrome.
  • 30 kcal/kg/day in older persons, but individually adjusted to nutritional status, physical activity level, disease status and tolerance.


Macronutrients

  • Protein- 1g/kg/day in older persons; individually adjusted to nutritional status, physical activity level, disease status and tolerance (12).
  • Fat and CHO ratio 30:70 when no respiratory deficiency. It is preferable to restrict CHOS (14).
  • High fibre content in diet (14).

Micronutrients

  • Vitamin D requires specific attention, particularly with lack of sun (10 micrograms (400 International units) per day (15).
  • Daily allowances for vitamins and trace elements (particularly A,D, E, B6 and B12, Ca, Zn and Se) should be ensured to malnourished patients at risk for or with COVID-19 (12, 14).


Notes

  • If malnutrition is identified, follow NICE guidelines, ACBS (Advisory Committee on Borderline Substances) indications can support strategies (16).
  • In any case, aim to include practical suggestions for meals and snacks, deal with symptoms such as fatigue, nausea, or loss of taste (15) as long as is not contradictory. Ensure adequate protein, vitamin and mineral intakes are achieved.
  • Role of fibre: studies demonstrate a lower incidence of bacterial translocation across the gut barrier with the administration of dietary fibre, suggesting that this nutrient modulates immunity. 25–38 g/day is advisable. Currently, there are no recommendations for fibre intake during the pandemic, but higher intakes may not be advisable due to the potential risk for gastrointestinal issues.
  • Explain that it is unknown if over the counter vitamins and supplements are helpful harmful or have no effect in treatment or ongoing symptoms (16).
  • Use food recalls to decide if further tests are needed to measure vitamin levels (17).

Importance of achieving adequate micronutrients levels

  • Vitamin C: doses above 200 mg/day might not benefit healthy individuals.
  • On balance, Vitamin D supplementation was safe, and it protected against acute respiratory tract infection overall.
  • Vitamin E deficiency impairs both humoral and cell-mediated immune functions.
  • It has been suggested that a Zinc intake of 30–50 mg/d might aid in the control of RNA viruses such as influenza and coronaviruses.
  • While there has been no recommended dietary intake of copper against COVID-19, a copper intake of 7.8 mg/d has been shown to reduce oxidative stress and alter immune function, albeit it is unknown whether those changes were beneficial.
  • Magnesium has antioxidants and inhibits release of inflammatory cytokines the development of low calcium and magnesium needs to be monitored for in persons with COVID-19.


Pay attention to beta carotene which is an antioxidant: sweet potatoes carrots and green leafy vegetables have them. Vitamins C and E which are a common antioxidant found in nuts seeds spinach and broccoli. Vitamin D can be found in fortified cereals and plant-based milk and supplements and Zinc is found in nuts pumpkin seeds sesame seeds beans lentils. 100 to 200 milligrams of vitamin C demonstrated to be satisfactory to optimise cell and tissue levels for the lessening of persistent dangers, however an excess of vitamin C can harm kidney particularly with more than 1000 milligrams per day (18).

Enteral or parenteral nutrition

Indications

Unless there is dysphagia or neurological dysfunction (15) or when nutritional needs cannot be met orally or through enteral nutrition for more than three days (12). Consider logistics at home. Safety and practice are secondary to this hub but you can consult with your rehabilitation team (15).

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References

Front-line dietary advice

(1) Barazzoni R, Bischoff SC, Breda J, Wickramasinghe K, Krznaric Z, Nitzan D, et al. ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection. Clinical Nutrition. 2020 Jun;39(6):1631–8.

(2) A Community Healthcare Professional Guide to the Nutritional Management of Patients During and After COVID-19 Illness. :9.

(3) Cawood AL, Walters ER, Smith TR, Sipaul RH, Stratton RJ. A Review of Nutrition Support Guidelines for Individuals with or Recovering from COVID-19 in the Community. Nutrients. 2020 Oct 22;12(11):3230.

(4) Weekes CE, Emery PW, Elia M. Dietary counselling and food fortification in stable COPD: a randomised trial. Thorax. 2009 Jan 8;64(4):326–31.

(5) COVID-19 Recovery - Therapy Information Pack - Swansea Bay University Health Board [Internet]. [cited 2021 Jan 18]. Available from: https://sbuhb.nhs.wales/recovery-wellbeing/about-recovery-wellbeing/covid-19-recovery-therapy-information-pack/

(6) Louca P, Murray B, Klaser K, Graham MS, Mazidi M, Leeming ER, et al. Modest effects of dietary supplements during the COVID-19 pandemic: insights from 445 850 users of the COVID-19 Symptom Study app. BMJ Nutr Prev Health [Internet]. 2021 Mar [cited 2021 May 25]; Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8061565/

(7) Calder PC. Nutrition, immunity and COVID-19. BMJ Nutrition, Prevention & Health [Internet]. 2020 Jun 1 [cited 2020 Aug 31];3(1). Available from: https://nutrition.bmj.com/content/3/1/74

(8) COVID-19 rapid guideline: vitamin D. vitamin D. :15.

(9) National guidance for post-COVID syndrome assessment clinics (6 November 2020) [Internet]. Patient Safety Learning - the hub. [cited 2021 Jan 9]. Available from: https://www.pslhub.org/learn/coronavirus-covid19/guidance/national-guidance-for-post-covid-syndrome-assessment-clinics-6-november-2020-r3465/

(10) Lawrence V, Hickson M, Weekes E, Julian A, Frost G, Murphy J. A UK survey of nutritional care pathways for Covid-19 patients post hospital stay. Journal of Human Nutrition and Dietetics. submitted.

(11) COVID-19 rapid guideline: managing the long-term effects of COVID-19. :35.


Advanced dietary advice

(12) Barazzoni R, Bischoff SC, Breda J, Wickramasinghe K, Krznaric Z, Nitzan D, et al. ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection. Clinical Nutrition. 2020 Jun;39(6):1631–8.

(13) Brugliera L, Spina A, Castellazzi P, Cimino P, Arcuri P, Negro A, et al. Nutritional management of COVID-19 patients in a rehabilitation unit. Eur J Clin Nutr. 2020 Jun;74(6):860–3.

(14) Aytür YK, Köseoğlu BF, Taşkıran ÖÖ, Ordu-Gökkaya NK, Delialioğlu SÜ, Tur BS, et al. Pulmonary rehabilitation principles in SARS-COV-2 infection (COVID-19): A guideline for the acute and subacute rehabilitation. :17.

(15) Cawood AL, Walters ER, Smith TR, Sipaul RH, Stratton RJ. A Review of Nutrition Support Guidelines for Individuals with or Recovering from COVID-19 in the Community. Nutrients. 2020 Oct 22;12(11):3230.

(16) National guidance for post-COVID syndrome assessment clinics (6 November 2020) [Internet]. Patient Safety Learning - the hub. [cited 2021 Jan 9]. Available from: https://www.pslhub.org/learn/coronavirus-covid19/guidance/national-guidance-for-post-covid-syndrome-assessment-clinics-6-november-2020-r3465/

(17) Lawrence V, HIckson M, Weekes E, Julian A, Frost G, Murphy J. A UK survey of nutritional care pathways for Covid-19 patients post hospital stay. Journal of Human Nutrition and Dietetics. submitted.

(18) Zabetakis I, Lordan R, Norton C, Tsoupras A. COVID-19: The Inflammation Link and the Role of Nutrition in Potential Mitigation. Nutrients. 2020 May 19;12(5):1466.