November/December 2021 Issue
MNT for Long COVID Patients
By Densie Webb, PhD, RD
Today’s Dietitian
Vol. 23, No. 9, P. 40
Today’s Dietitian explores how nutrition interventions may help alleviate long-term symptoms.
The COVID-19 pandemic continues to wreak havoc across the United States and the world, and it’s leaving behind long-term health consequences. While many COVID-19 patients recover within a few weeks, some experience persistent or new symptoms more than four weeks after first being diagnosed—with some still exhibiting shortness of breath and fatigue up to nine months later.1 Preliminary research out of the United Kingdom found that almost 38% of symptomatic people experienced at least one symptom post COVID-19, while 14.8% experienced three or more symptoms lasting 12 weeks or more.2
Dubbed “long COVID,” the condition was dismissed early in the pandemic by the medical community but now is recognized as a public health problem. The National Institutes of Health plans to spend $1.15 billion over four years to study the effects of long COVID with the goals of better understanding the biological basis of long COVID and what makes some people more vulnerable to the condition than others—with a view towards eventually finding treatments.3 It’s unclear whether nutrition therapies will be a part of that research.
According to a recent report, the top post-COVID symptoms include pain, difficulty breathing, elevated cholesterol, persistent fatigue, and hypertension.1 These were the findings from studying the insurance records of more than 1.9 million COVID-19 patients between February 2020 and February 2021, before the Delta variant had widely spread. However, even before Delta, long COVID was considered new and had been relatively unstudied. It has been suggested that the nutritional impact of COVID has been massively underestimated and that nutrition therapy should be an important part of treating patients with long COVID.
Today’s Dietitian investigates how, in the face of few well-researched dietary protocols, MNT is being used to treat long COVID.
What Is Long COVID?
Definitions vary, but the National Health Service in England describes long COVID as “symptoms that develop during or after an infection consistent with COVID-19, continue for more than 12 weeks, and are not explained by an alternative diagnosis.”4 Long COVID goes by various names, including post–COVID-19 syndrome, postacute sequelae of COVID-19, and postacute sequelae of SARS-CoV-2.
There’s little research on treating long COVID patients, but there’s even less on MNT as a part of that treatment. However, there are clinics located in almost every state that specifically deal with treating long COVID patients. Much of the approach is based on experience with well-established dietary protocols for treating patients with other conditions that carry similar symptoms. But even among those clinics, few focus on nutrition therapy as part of their approach.
What Causes Long COVID?
Why some patients develop long COVID and others don’t is still a mystery. In the beginning, studies examined only people who’d been hospitalized with acute COVID. Among that population, between 33% to 87% of patients reported at least one symptom persisting after several months.5
However, there now appears to be no relation between the severity of the illness and the development of long COVID, though the occurrence of long COVID is age dependent and is more common among women than men. Even patients who experience mild symptoms after being diagnosed can suffer from long COVID. While questions remain, there are theories. Research suggests that obesity, smoking, or vaping is associated with a higher probability of persistent symptoms.2 One of the most discussed ideas is that COVID may lead to the development of mast cell activation syndrome, in which mast cells release histamine in response to the viral infection, which causes inflammation, triggering an array of prolonged symptoms.6 Another idea is that fragments of the virus, such as protein molecules, may persist for months and disrupt the body in some way, even if they’re not infectious.7
Post-COVID Nutrition Therapy
While MNT for COVID-19 isn’t well established, dietitians counseling post-COVID patients emphasize the importance of nutrition in the therapeutic approach for long COVID. “It is important to preserve nutrition status and prevent or treat malnutrition,” says Jennifer Brennan, RD, CDN, part of the nutrition leadership team for Sodexo in Fair Haven, New Jersey. “This in turn has the potential to reduce complications and improve outcomes related to COVID-19 infection.” In fact, she says that identifying and addressing malnutrition is critical for the individual care of the long COVID patient.
Megan A. Wroe, MS, RD, CNE, CLEC, wellness manager of the Wellness Center at St. Jude Medical Center in Fullerton, California, one of the only locations that provides nutrition assistance for COVID recovery in Southern California, says most of the “long-haulers” she sees already have been through rehab and are relatively stable, but still are dealing mostly with fatigue and headaches. She says dietitians are having to use previous knowledge of how nutrition can help in other conditions with similar symptoms, along with a smattering of newly released data to help their patients. “Without a medical nutrition therapy protocol, outpatient centers are going to be hesitant about offering advice on the subject.” At this point, she says, it’s a lot of trial and error.
Protein Intake
One of the considerations is making sure patients are getting adequate protein in their diets. “So many patients report weakness and fatigue long after having had COVID,” Wroe says. “We do body composition assessments and find that most of our clients show muscle loss, even alongside fat mass accumulation, in some cases.” She says she recommends higher-than-average–protein diets, closer to the 1.2 g/kg/day used in surgical recovery, in her long COVID clients.
Brennan emphasizes that, apart from COVID-19, loss of lean body mass and subsequent muscle weakness has been observed for as long as two years in patients hospitalized for severe respiratory conditions. While COVID-19 is still shy of two years, it’s something to be aware of when addressing the nutrition needs of long COVID patients in the future.
Loss of Taste
Another common side effect long COVID patients experience is loss of taste. Wroe says treatment for loss of taste is tricky, because it’s so variable among patients. “We rely a lot on recommendations for patients undergoing chemotherapy, who also experience loss of taste and smell,” Wroe says. She suggests patients eat warm foods to enhance flavor and add aromatics such as garlic and onion to improve smell. She also suggests chewing on herbs such as basil, mint, or fennel to clean the palate and to consume fewer processed foods. “So many of these [processed] foods have the ‘bliss point’ of sugar, salt, and fat, which can override true sense of taste.” If you’re unfamiliar with the term, the “bliss point” is the point where the levels of saltiness, sweetness, and richness are perceived as being just right and, under ordinary circumstances, make foods “craveable.”8
Brennan suggests that if patients are having difficulty coordinating chewing and breathing, beverages may be a better option than solid foods to efficiently increase energy intake. She adds that it’s important to provide oral rehydration solutions if patients are struggling with fluid intake or experiencing vomiting and diarrhea.
Low-Histamine Diet
As mentioned earlier, one theory behind the cause of long COVID is elevated levels of histamines. Some health professionals have advocated low-histamine diets to minimize long COVID’s inflammatory effects and help alleviate its symptoms, but there’s little evidence to back that approach. Low-histamine diets require avoidance of several foods including canned, fermented, or pickled fish; fermented dairy; cured or processed meat; fruits and vegetables such as oranges, bananas, spinach, and tomatoes; wine and beer; and peanuts and tree nuts. As a result, these diets can be difficult to follow.
Intermittent Fasting
Some animal and human studies have suggested that intermittent fasting regimens may be beneficial for COVID patients, promoting metabolic benefits such as weight loss, reduced adiposity, and improved glucose homeostasis, all of which may be beneficial during COVID-19 recovery.9-11
Wroe says intermittent fasting for long COVID patients, if done properly, may help reinvigorate the metabolic process and stimulate autophagy, the body’s way of cleaning out damaged cells to regenerate newer, healthier cells, which may be helpful to the immune system and, ultimately, beneficial to recovery from COVID. While intermittent fasting may be helpful for some long COVID patients, it may not be appropriate for all, especially those who are underweight and malnourished.
Supplements
While no widely accepted protocol exists for long COVID with regard to supplements, Wroe says she recommends vitamin D (~4,000 IU/day) and quality omega-3s for most long COVID patients. She also says magnesium may help with muscle aches, and soluble fiber can help with constipation,
which is common, she says.
“It’s exciting as an RD to think of vitamins, minerals, or other nutritional supplements being one of the keys to treating COVID-19 patients,” Brennan says. “We know that vitamins and minerals play a role in the immune system and have helped patients with other conditions.” However, Brennan has a caveat. “It’s critical to look closely at the evidence before making these recommendations, especially with a novel virus like COVID-19.”
One area of interest to researchers, Brennan says, is the use of probiotics in the treatment of long COVID symptoms. The hypothesis is that a gut microbiota that’s already disturbed from a poor diet, opportunistic microbes, or medications may be associated with long COVID symptoms. It’s only a conjecture at this point, but there are other potential benefits to consuming probiotics—alleviating symptoms of long COVID may be among them.
Patient Perspective
If there’s one truism about long COVID, it’s that every patient’s experience is different. Lynne Millington-Baker, RN, BSN, CPPS, of Emory University Hospital Midtown in Atlanta, was diagnosed with COVID-19 in July 2020 and is still dealing with symptoms, such as overwhelming fatigue and joint pain. She says both she and her husband had the virus. He recovered well; she didn’t. In addition to seeing an array of medical specialists, she’s tried several nutritional approaches—some with the advice of a dietitian colleague, some on her own—including supplements (vitamins C and D, chromium, and zinc). In addition, she’s read books on anti-inflammatory diets and has tried that but says the diet was too difficult to follow. She’s had more luck with the Mediterranean diet, which is known to have anti-inflammatory effects. She also drinks turmeric and ginger teas for their anti-inflammatory properties. Most recently, she tried intermittent fasting and says it has helped with her weight and energy levels.
While Millington-Baker’s experience is hers alone, it’s an example of how patients suffering from COVID’s long-term effects are hungry for advice and willing to try almost anything to feel well again.
Nutrition Therapy With Comorbidities
For COVID-19 patients with comorbidities, such as hypertension, diabetes, and obesity, the risk of long COVID is even greater. However, Wroe says dietary recommendations for COVID-19 patients with metabolic comorbidities are no different from the same patients without COVID-19. “Anti-inflammatory diet recommendations that help stabilize blood sugar and improve blood pressure also are recommended for patients with COVID. Anything that helps metabolic conditions is going to help immune function, too.”
Weight Management With Long COVID
Despite the use of the same nutrition therapy for patients with or without COVID who have comorbidities, long COVID can have opposite effects on weight, thereby warranting different approaches to treatment. If patients experience a loss of taste and smell that continues, they can lose their appetite and weight loss may follow. Greater inflammation and longer durations of the disease are associated with weight loss.7
On the other hand, if their appetite is stable but chronic fatigue prevents them from returning to usual activities, weight gain can result. While there’s limited, if any, research on the weight gain aspect, dietitians working with long COVID patients say it’s a real issue and, as with any weight management program, must be approached on an individual basis.12 “Most clients I see who need to lose weight post COVID needed to lose weight pre-COVID as well and therefore need to focus on realistic and attainable goals, just like any other patient,” Wroe says. The biggest culprit, she says, is the desire for comfort foods that tend to be high in fat, sugar, and calories.
What Can RDs Do?
As dietitians consulting patients suffering from long COVID, it’s important to understand that the disease is still relatively new and as such is poorly understood. The number and severity of lingering symptoms may vary greatly for each patient. The most important aspect of counseling clients who have any type of condition, but especially long COVID, is to listen. Offering suggestions based on experience counseling patients with similar symptoms from other conditions and formulating advice based on the limited experience of other dietitians advising long COVID patients, is the best approach until more research becomes available. Wroe says her COVID recovery program focuses on small, achievable goals such as daily breath work, short bouts of functional movement, and stretches, paired with ideas for anti-inflammatory meals and snacks. Brennan offers these final words of advice: “The consumption of a diet high in fresh, unprocessed foods, dietary fiber, and natural probiotics are the best defenses for preventing and treating long COVID.”
— Densie Webb, PhD, RD, is a freelance writer, editor, and industry consultant based in Austin, Texas.
[Sidebar]
Resources
To hear from long COVID patients, visit the Facebook group Long Covid Support Group at facebook.com/groups/longcovid. To refer clients and patients to a clinic that specializes in long COVID, visit survivorcorps.com/pccc for locations across the country.
References
1. FAIR Health. A detailed study of patients with long-haul COVID: an analysis of private healthcare claims. https://s3.amazonaws.com/media2.fairhealth.org/whitepaper/asset/A%20Detailed%20Study%20of%20Patients%20with%20Long-Haul%20COVID--An%20Analysis%20of%20Private%20Healthcare%20Claims--A%20FAIR%20Health%20White%20Paper.pdf. Published June 15, 2021.
2. Whitaker M, Elliott J, Chadeau-Hyam M, et al. Persistent symptoms following SARS-CoV-2 infection in a random community sample of 508,707 people. medRxiv website. https://www.medrxiv.org/content/10.1101/2021.06.28.21259452v1. Published July 3, 2021.
3. Subbaraman N. US health agency will invest $1 billion to investigate 'long COVID.' Nature. 2021;591(7850):356.
4. National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing the long-term effects of COVID-19. https://www.nice.org.uk/guidance/ng188/resources/covid19-rapid-guideline-managing-the-longterm-effects-of-covid19-pdf-66142028400325. Published December 18, 2020.
5. Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome. Nat Med. 2021;27:601-615.
6. Kritas SK, Ronconi G, Caraffa A, Gallenga CE, Ross R, Conti P. Mast cells contribute to coronavirus-induced inflammation: new anti-inflammatory strategy. J Biol Regul Homeost Agents. 2020;34(1):9-14.
7. Marshall M. The four most urgent questions about long COVID. Nature. 2021;594(7862):168-170.
8. Rao P, Rodriguez RL, Shoemaker SP. Addressing the sugar, salt, and fat issue the science of food way. NPJ Sci Food. 2018;2:12.
9. Ealey KN, Phillips J, Sung HK. COVID-19 and obesity: fighting two pandemics with intermittent fasting. Trends Endocrinol Metab. 2021;32(9):706-720.
10. Mccalmon S, Galappaththy SL, Bulchandani S, Cabandugama PK. Fasting off “the COVID-19.” Mo Med. 2021;118(2):164-167.
11. Lee JH, Verma N, Thakkar N, Yeung C, Sung HK. Intermittent fasting: physiological implications on outcomes in mice and men. Physiology (Bethesda). 2020;35(3):185-195.
12. AHP Leader. Long COVID dietitians. YouTube website. https://www.youtube.com/watch?v=SsQQwYmmv3o. Published April 12, 2021. Accessed September 9, 2021.