Managing symptoms linked to nutrition during COVID-19 recovery

Information to help professionals manage patient symptoms linked to nutrition

Consensus statements from expert panels

  • Healthcare professionals require a professional toolbox to assist them in supporting patients effectively. The toolbox should outline the range of potential symptoms and scenarios to allow them to select and combine based on patient needs, situation, barriers.
  • Patients want to understand the underlying mechanism or cause of symptoms, rather than to simply focus on the management of the symptom. Healthcare professionals need to offer consistent advice by trying and addressing this desire, as well as support symptom management.

 

The following list provides an approximate prevalence of symptoms that are included in the symptom toolkit found below on this page because they affect or are affected by diet and nutrition:

  • Musculoskeletal such as muscle aches, fatigue, joint pain and chest tightness (94%)
  • Pulmonary and respiratory symptoms such as shortness of breath, dry cough or breathing difficulties (93%)
  • Impact of cognitive dysfunction/memory on daily abilities and impact by age (88%)
  • Changes to emotion and mood (88%)
  • Gastrointestinal symptoms such as diarrhoea, nausea and loss of appetite (86%)
  • Cardiovascular symptoms such as heart palpitations, tachycardia pain in the test (86%)
  • Brain fog/cognitive dysfunction and memory impairment (85%)
  • Sleep difficulties (79%)
  • Headaches (77%)
  • Sore throat (60%)
  • Changes to taste and smell (58%)
  • Extreme thirst (36%)


The three most debilitating symptoms referenced by patients were:

  • fatigue
  • breathing issues
  • cognitive dysfunction.


Patients with long COVID can experience relapsing symptoms (at least 85%) but patterns can be irregular. Relapses were commonly triggered by physical activity, stress and mental activity. Heat and alcohol, as well as high-sugar foods and foods high in histamines were also mentioned, although with reduced frequency.

Whilst there is a subset of long COVID population who meet Chronic Fatigue Syndrome (CFS/ME) diagnostic criteria, there is a significant subpopulation with fatigue that do not meet the criteria and therefore these mechanisms require further investigation.

Symptom toolkit

The information below lists groups of symptoms that may influence nutritional status or be influenced by diet and/or nutrition, as identified from various documents (1–6).

Several sections in this hub contain valuable information relating to each group of symptoms, thus useful links have been added to support navigation to other resources.

Systemic

Symptoms

  • Dizziness
  • Decreased activity endurance
  • Post-exertional malaise
  • Muscle and weight loss
  • Low energy or tiredness
  • Weakness
  • Pain, headaches, chest tightness
  • Fatigue


What does it have to do with the patient’s nutrition and diet?

  • Pain and fatigue may prevent from eating the energy or nutrients patients need.
  • Decreased activity endurance may prevent the habit of exercising, which in turn may affect control measures for chronic diseases such as hypertension, diabetes and obesity.
  • Not eating enough calories – especially protein – will result in low energy, trouble sleeping, and other symptoms.


Useful
 links to address some of these symptoms

Respiratory

Symptoms

  • Coughing
  • Breathlessness
  • Gas trapping and early satiety
  • Dry mouth due to breathing through the mouth


What does it have to do with the patient’s nutrition and diet?

  • What patients eat (texture, quantity, spices, etc.) may aggravate breathing difficulties.
  • Gulping air can happen whilst eating, which may bring more difficulties for accepting certain types of healthy foods (e.g. high in fibre).


Useful links to address some of these symptoms

Gut

Symptoms

  • Changed taste and smell (anosmia)
  • Reduced or increased appetite
  • Reduced food intake
  • Feeling full
  • Lack of enjoyment of food and eating
  • Dry mouth
  • Swallowing problems (dysphagia) – particularly after intubation in ICU
  • Diarrhoea or hyperactive bowel sensations
  • Increased need for specific nutrients and/or fluid when intake may be poor


What does it have to do with the patient’s nutrition and diet

  • Digestion of food and nutrient absorption happens throughout patients’ gut; the process begins from the moment they smell food, continues as they chew in the mouth and swallow until excretion of what was not absorbed.
  • If one or more symptoms prevent patients from eating (at all or enough), there is a risk of not meeting their nutrients and caloric needs, or overeating foods that are not nutritious. In return, overeating can lead to problems that can be addressed with diet.
  • Diarrhoea may also cause to lose essential nutrients and therefore adjustments are needed regarding diet.


Useful links to address some of these symptoms

Psychological and cognitive dysfunctions

Symptoms

  • Sleep disorders
  • Anxiety
  • Fear
  • Apathy
  • Depression
  • Despair, hallucinations
  • Low mood


What does it have to do with the patient’s nutrition and diet

  • Emotional states affect what we choose to eat, and some foods can be eaten as emotional comfort. 
  • Low mood, apathy and other symptoms can also prevent us from eating at all, hence affecting our nutrition.


Useful
 links to address some of these symptoms

Social and occupational effects

Symptoms

  • Poor food availability and accessibility for those who struggle to go to the shops
  • Lack of visits from family or friends to provide food, company and feeding assistance
  • Cancellation of social lunch clubs.
  • Low work productivity

What does it have to do with the patient’s nutrition and diet?

  • Lack of variety in patients’ diet may prevent them from receiving all nutrients and calories they are used to.
  • Changes in social support networks may negatively influence mood and what patients feel like eating and what they can eat.
  • Not meeting protein and vitamin requirements may trigger feeling tired at work.


Useful
 links to address some of these symptoms

Functional

Symptoms

  • Impact on a patient’s ability to undertake normal activities of daily living, such as shopping and cooking, self-care, mobility


What does it have to do with the patient’s nutrition and diet?

  • Shopping practices affect our eating habits, and daily activities may be impacted if diets are unhealthy.


Useful
 links to address some of these symptoms

Metabolic associated problems

Symptoms

  • Obesity
  • Diabetes
  • High blood pressure
  • Heart disease


What does it have to do with the patient’s nutrition and diet?

  • These diseases relate to nutrition since what we eat may worsen or improve each of them and may require additional dietary changes on top of what COVID-19 symptoms may produce.


Useful links to address some of these symptoms

Symptoms affecting nutrition and how to address them

Clinical recommendations

Considering the intermittent nature of COVID-19 symptoms, any association with nutrition may be challenging to identify. Symptom severity will also determine the impact COVID-19 has on nutrition and diet, whilst one mild symptom may be tolerable, several mild symptoms together can be very debilitating (7). Symptoms such as anosmia, dysgeusia or diarrhoea or these altogether increase risk of disease-related malnutrition (8).

Issues that affect dietary intake:

  • Respiratory: coughing and breathlessness, gas trapping and early satiety, caused by gulping air whilst eating, Dry mouth due to breathing through the mouth, use of inhalers and oxygen therapy.
  • Changes to taste and smell impact appetite and desire to eat – for more information please see our Underlying mechanisms for COVID-19 symptoms page.
  • Temperature, infection and inflammation: inflammatory response can suppress appetite and alter metabolism, increasing the need for specific nutrients and fluid when intake may be poor – for more information please our Underlying mechanisms for COVID-19 symptoms page.
  • Fatigue and weakness impact on a patient’s ability to undertake normal activities of daily living, such as shopping and cooking.
  • Isolation impacts nutritional intake e.g. poor food availability and accessibility for those who struggle to go to the shops. Lack of visits from family or friends to provide food, company and feeding assistance. Cancellation of social lunch clubs.


Useful resources

The BDA Critical Care Specialist group provides eating recommendations after critical illness that can be offered to patients.


The Action for ME charity provides detailed guidance (booklet) to support making an informed decision about various pacing approaches worth trying to address fatigue, weakness and other related symptoms.


There are various documents in the NHS archive that point to the use of aromatherapy to address sleep and anxiety issues:

Nutritional assessment for long COVID

This is defined as symptoms persisting 12 weeks or more after the onset of the first symptom (4). Although lungs are considered the main target organ of COVID-19, the virus can affect many other organs, including heart and blood vessels, kidneys, gut and brain through other mechanisms (6). Gut symptoms and fatigue may be associated with the psychological and physical processes of having suffered COVID-19, which does not mean that it is unrelated.

Comfort eating may be an issue due to low energy, low mood and anxiety after having overcome the acute phase of COVID-19. Be sensitive to terms which may be associated with mental health. Avoid dismissing patients thinking that healthcare professionals hold all answers.

Symptoms of ongoing and post COVID-19 syndrome (1, 4), which are related to nutrition, are:

  • systemic and musculoskeletal: fatigue, post-exertional malaise and pain
  • neuropsychiatric: sleep disturbance and dizziness. Emotion and mood (anxiety).
  • gastrointestinal: nausea, diarrhoea, anorexia and reduced appetite.
  • cardiovascular: breathlessness, myalgia and cough – myocardial injury is the most common complication, thus self-monitor blood pressure and pulse oximetry may help.
  • genitourinary and endocrine: liver disfunction and symptoms related to urinary function. Low and high blood glucose levels may also be common.

Further information can be found:


Screening questionnaires

No nutritional screening questionaries have been validated to identify nutritional issues in COVID-19. However, the suggested questionnaire – the COVID-19 Yorkshire Rehab Screen Tool (2, 4) – available from the Advances in Clinical Neuroscience and Rehabilitation website, could be used at the initial consultation as well as to measure progress. The questionnaire can also be completed by the patient, allowing them to self-monitor if appropriate, its scope covers:

  • People with COVID-19 symptoms who have been managed at home. Symptoms may include: fatigue, breathlessness, cough, low physical strength, anosmia, lost sense of taste, sleep disturbance, low mood, anxiety, weight loss (>3 kg) or other symptoms.
  • Older adults. When investigating possible causes of a gradual decline, deconditioning, worsening frailty or dementia, or loss of interest in eating and drinking in older people, bear in mind that these can be signs of ongoing symptomatic COVID-19 or suspected post-COVID-19 syndrome.

The questionnaire tool aims to identify breathlessness, airway complications, swallowing, fatigue, continence, anxiety, depression, family/carers views are influenced by or can influence nutrition. Regarding nutrition alone, some questions that this tool asks and that can be used alone to assess affectations at a nutritional and dietary level are:

  • Are you or your family concerned that you have ongoing weight loss or any ongoing nutritional concerns as a result of COVID-19? Yes ☐ No ☐
  • Please rank your appetite or interest in eating on a scale of 0-10 since COVID-19 (0 being same as usual/no problems, 10 being very severe problems/reduction)

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References

(1) Davis HE, Assaf GS, McCorkell L, Wei H, Low RJ, Re’em Y, et al. Characterizing Long COVID in an International Cohort: 7 Months of Symptoms and Their Impact. medRxiv. 2021 Apr 5;2020.12.24.20248802.

(2) 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/

(3) NIHR Evidence - Living with Covid19 - webinars - Informative and accessible health and care research [Internet]. [cited 2021 Apr 26]. Available from: https://evidence.nihr.ac.uk/themedreview/living-with-covid19-webinars/?source=chainmail

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

(5) Wise J. Long covid: WHO calls on countries to offer patients more rehabilitation. BMJ. 2021 Feb 10;372:n405.

(6) Gem COVID. Post-COVID-19 global health strategies: the need for an interdisciplinary approach. Aging Clin Exp Res. 2020 Jun 11;1–8.

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

(8) Ballesteros Pomar MD, Bretón Lesmes I. Clinical Nutrition in times of COVID-19. Endocrinología, Diabetes y Nutrición (English ed). 2020 Aug;67(7):427–30.