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This knowledge hub is constantly being reviewed and updated. We welcome your comments or feedback about it.
Please contact abigail.troncohernandez@plymouth.ac.uk and we will get back to you promptly.
Information on first-line and advanced dietary advice for professionals
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. Aim for the 'Food first' principle, which means addressing all nutritional needs through the use of food rather than supplements (Barazzoni et al., 2020; Malnutrition Pathway, 2020).
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 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.
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).
Other points to consider:
Diet fortification
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 (e.g. people who cannot cook, will not cook, or do not know how to).
NHS Wales (Swansea Bay University Health Board, 2020) provides a website offering practical suggestions for patients who are recovering from COVID-19 on the following:
Available guidelines
Cawood et al. have reviewed nutrition support guidelines and this paper summarises key themes of those publications linked to nutrition support of adults with or recovering from COVID-19 outside of hospital (Cawood et al., 2020). The three themes across all guidelines include:
(i) screening for malnutrition, which can be achieved by remote consultation
(ii) care plans with appropriate nutrition support, which may include food based strategies, oral nutritional supplements and referral to a dietitian
(iii) continuity of nutritional care between settings including rapid communication at discharge of malnutrition risk and requirements for ongoing nutrition support.
This reflects the information provided in this knowledge hub.
National Institute for Health and Care Excellence (NICE)
Inflammation and histamine
The British Dietetic Association (BDA) released a statement – Low histamine diets and post-COVID syndrome [PDF] – after growing reports of people using a low histamine or similar types of diets.
They noted:
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 on the treatment of ongoing symptoms of COVID-19 (Cawood et al., 2020; Louca et al., 2021).
For other chronic health conditions similar to post-COVID syndrome 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. (Calder, 2020; NICE, PHE and SACN, 2020)
Several studies have shown relationship between some nutrients and recovery. There may be a possible role of vitamin D in the prevention and treatment of COVID-19, however there is no evidence yet that supplementation is necessary or beneficial, except in those who have a proven vitamin D deficiency. A serum vitamin D test is required to diagnose vitamin D deficiency. A supplement of 400IU is recommended for all adults in the UK during the winter months between September and March (NHS, 2020; NICE, PHE and SACN, 2020). A Korean study found those deficient in vitamin D and Selenium to be at higher risk of severe complications (Benarba and Khaled, 2021). Vitamin D deficiency however, does not alter the immune system significantly or differently than for other infections (Rodriguez-Leyva and Pierce, 2021).
Achieving vitamin K levels seems particularly relevant for COVID-19 recovery given the use of antibiotic across some patients which may decrease vitamin K pool, which is important for the gut’s microbiota (Segal et al., 2020).
This systematic review provides a range of evidence about the most common phytochemicals, micronutrients and nutraceuticals of interest for the treatment of COVID-19. (Ayseli et al., 2020).
The following herbal and plant components have been studied to assess their benefits to immunity: Curcumin, beta Glucan, Selenium, Astaxanthin, Ceruloplasmin, Myeloperoxidase, Quercetin, Resveratrol, Asplenium montanum (Naidu, Pressman and Clemens, 2021). There is very little and weak evidence to support the use of these supplements to support COVID-19 recovery. Supplements can potentially cause harm as well as benefit (Patel, Martindale and McClave, 2020), therefore it is advised to monitor response to any new supplement, take it for a fixed period of time and ideally introduce one supplement at a time. If you think your patient needs assistance in fortifying their diet, discuss this with a dietitian.
This checklist is divided in two sections. Section A is validated and should be used by a health professionals and section B can be self-applied. See the Malnutrition Task Force website for healthcare professionals and the Patient's Association website information about this tool’s update.
We encourage you to use the Patients Association nutrition checklist and functional measures (see list below) to start the conversation about patient nutritional needs. The use of functional measures listed below can avoid reliance on body weight as the sole criterion for instigating or changing, nutritional therapies. Body weight is not always the best measure to use and if infection control measures are in place it may not be possible to use it.
Potential outcome measures (NICE, 2020):
Access a library available for NHS staff to perform some of these tests (NHS Digital)
The European Society for Clinical Nutrition and Metabolism (ESPEN) published some guidelines (Barazzoni et al., 2020) on energy, macronutrient and micronutrient distribution.
Energy requirements (Barazzoni et al., 2020; Brugliera et al., 2020)
Macronutrients
Notes
Beta carotene is an antioxidant: sweet potatoes, carrots and green leafy vegetables have them. Vitamins C and E are a common antioxidant found in nuts, seeds, spinach and broccoli. Vitamin D can be found in fortified cereals and fortified plant-based milk and supplements. Zinc is found in nuts, pumpkin seeds, sesame seeds, beans and lentils. 100-200 milligrams of vitamin C has been demonstrated to optimise cell and tissue levels for the lessening of persistent viral infections, however an excess of vitamin C can harm kidneys, particularly with more than 1000 milligrams per day (Zabetakis et al., 2020).
The following is a list of herbal remedies that may have health claims related to COVID-19 (Namdeo, 2021). However, there are no human experiments including COVID-19 patients and therefore consuming these supplements may pose a risk to health:
Indications
Unless there is dysphagia or neurological dysfunction (Cawood et al., 2020) or when nutritional needs cannot be met orally or through enteral nutrition for more than three days (Barazzoni et al., 2020). Consider logistics at home. Safety and practice are not included in this hub but you can consult with your rehabilitation team (Cawood et al., 2020).
Further advice is available from the BDA and the Critical Care specialist group.
This knowledge hub is constantly being reviewed and updated. We welcome your comments or feedback about it.
Please contact abigail.troncohernandez@plymouth.ac.uk and we will get back to you promptly.
Ayseli, Y.I. et al. (2020) ‘Food policy, nutrition and nutraceuticals in the prevention and management of COVID-19: Advice for healthcare professionals’, Trends in Food Science & Technology, 105, pp. 186–199. doi:10.1016/j.tifs.2020.09.001.
Aytür, Y.K. et al. (2020) ‘Pulmonary rehabilitation principles in SARS-COV-2 infection (COVID-19): A guideline for the acute and subacute rehabilitation’, p. 17.
Barazzoni, R. et al. (2020) ‘ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection’, Clinical Nutrition, 39(6), pp. 1631–1638. doi:10.1016/j.clnu.2020.03.022.
Bassatne, A. et al. (2021) ‘The link between COVID-19 and VItamin D (VIVID): A systematic review and meta-analysis.’, Metabolism: clinical and experimental, 119(mum, 0375267), p. 154753. doi:10.1016/j.metabol.2021.154753.
Benarba, B. and Khaled, M.B. (2021) ‘New insight on nutrition and COVID-19 pandemic’, The North African Journal of Food and Nutrition Research, 4, pp. S1–S2. doi:10.51745/najfnr.4.10.S1-S2.
Brugliera, L. et al. (2020) ‘Nutritional management of COVID-19 patients in a rehabilitation unit’, European Journal of Clinical Nutrition, 74(6), pp. 860–863. doi:10.1038/s41430-020-0664-x.
Butler, T. et al. (2020) Joint BACPR/BDA/PHNSG statement on nutrition and cardiovascular health post-COVID-19 pandemic. Available at: https://bjcardio.co.uk/2020/09/joint-bacpr-bda-phnsg-statement-on-nutrition-and-cardiovascular-health-post-covid-19-pandemic/ (Accessed: 22 October 2021).
Calder, P.C. (2020) ‘Nutrition, immunity and COVID-19’, BMJ Nutrition, Prevention & Health, 3(1). doi:10.1136/bmjnph-2020-000085.
Cawood, A.L. et al. (2020) ‘A Review of Nutrition Support Guidelines for Individuals with or Recovering from COVID-19 in the Community’, Nutrients, 12(11), p. 3230. doi:10.3390/nu12113230.
Hanson, C. et al. (2016) ‘The Relationship between Dietary Fiber Intake and Lung Function in the National Health and Nutrition Examination Surveys’, Annals of the American Thoracic Society, 13(5), pp. 643–650. doi:10.1513/AnnalsATS.201509-609OC.
Lawrence, V. et al. (2021) ‘A UK survey of nutritional care pathways for patients with COVID-19 prior to and post-hospital stay’, Journal of human nutrition and dietetics: the official journal of the British Dietetic Association, 34(4), pp. 660–669. doi:10.1111/jhn.12896.
Lockyer, S. (2020) ‘Effects of diets, foods and nutrients on immunity: Implications for COVID-19?’, Nutrition Bulletin, 45(4), pp. 456–473. doi:10.1111/nbu.12470.
Louca, P. et al. (2021) ‘Modest effects of dietary supplements during the COVID-19 pandemic: insights from 445 850 users of the COVID-19 Symptom Study app’, BMJ Nutrition, Prevention & Health [Preprint]. doi:10.1136/bmjnph-2021-000250.
Malnutrition Pathway (2020) ‘A Community Healthcare Professional Guide to the Nutritional Management of Patients During and After COVID-19 Illness’, p. 9.
Naidu, A.S., Pressman, P. and Clemens, R.A. (2021) ‘Coronavirus and Nutrition: What Is the Evidence for Dietary Supplements Usage for COVID-19 Control and Management?’, Nutrition Today, 56(1), pp. 19–25. doi:10.1097/NT.0000000000000462
Namdeo, P. (2021) ‘A Review on Herbal Immunity Booster and Nutrition W – To Fight against COVID-19’, 2021, p. 12.
NHS (2020) National guidance for post-COVID syndrome assessment clinics (6 November 2020), Patient Safety Learning – the hub. Available at: https://www.pslhub.org/learn/coronavirus-covid19/guidance/national-guidance-for-post-covid-syndrome-assessment-clinics-6-november-2020-r3465/ (Accessed: 9 January 2021).
NICE (2020) ‘COVID-19 rapid guideline: managing the long-term effects of COVID-19’, p. 35.
NICE, PHE and SACN (2020) ‘COVID-19 rapid guideline: vitamin D’, vitamin D, p. 15.
Patel, J.J., Martindale, R.G. and McClave, S.A. (2020) ‘Relevant Nutrition Therapy in COVID-19 and the Constraints on Its Delivery by a Unique Disease Process’, Nutrition in Clinical Practice, 35(5), pp. 792–799. doi:10.1002/ncp.10566
Rodriguez-Leyva, D. and Pierce, G.N. (2021) ‘The Impact of Nutrition on the COVID-19 Pandemic and the Impact of the COVID-19 Pandemic on Nutrition’, Nutrients, 13(6), p. 1752. doi:10.3390/nu13061752.
Segal, J.P. et al. (2020) ‘The gut microbiome: an under-recognised contributor to the COVID-19 pandemic?’, Therapeutic Advances in Gastroenterology, 13, p. 1756284820974914. doi:10.1177/1756284820974914.
Swansea Bay University Health Board (2020) COVID-19 Recovery – Therapy Information Pack. Available at: https://sbuhb.nhs.wales/recovery-wellbeing/about-recovery-wellbeing/covid-19-recovery-therapy-information-pack/ (Accessed: 18 January 2021).
Weekes, C.E., Emery, P.W. and Elia, M. (2009) ‘Dietary counselling and food fortification in stable COPD: a randomised trial’, Thorax, 64(4), pp. 326–331. doi:10.1136/thx.2008.097352.
Zabetakis, I. et al. (2020) ‘COVID-19: The Inflammation Link and the Role of Nutrition in Potential Mitigation’, Nutrients, 12(5), p. 1466. doi:10.3390/nu12051466.
In creating the knowledge hub we worked with expert panels to form a consensus on the nutritional care for people recovering from COVID-19 infection. Each section of the knowledge hub includes a consensus statement produced by the relevant expert panel. For information on the background of the Nutrition and COVID-19 recovery knowledge hub project visit the 'about us' page.
Consensus statements from expert panels