Supporting patients with advice during COVID-19 recovery

Information on first-line and advanced dietary advice for professionals

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. 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 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. For example; if weight change is one problem (either loss or gain) preventing further change may be the best goal in the first instance.
  • 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 of nutritional supplement 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.

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:

  • There may be long term issues with the diet that could have been neglected and now is an opportunity to improve them.
  • Consistent information is important to patients. Consider patients communication needs and food culture e.g. reading level, braille, relevance to their culture etc
  • Offer suggestions for meals and snacks (Cawood et al., 2020) (see links provided above).

Diet fortification

  • For patients with chronic obstructive pulmonary disease and nutritionally at risk, fortifying diet with milk powder, resulted in outcome improvements (Weekes, Emery and Elia, 2009).
  • If a patient needs support to fortify their diet, over the counter nutritional supplements can be helpful (Cawood et al., 2020). See Importance of achieving adequate micronutrients levels within the Advanced dietary advice section below for further information.


Food first tips for eating more or eating differently
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:

  • 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

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)



Emerging evidence
Inflammation and histamineThe 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:

  • Histamine in the body is high to support and defend our bodies against infections (such as COVID-19), and this can cause a wide range of symptoms including bloating, diarrhoea, nausea, headache, rhinitis, wheezing, hypotension, arrhythmia, urticaria, itching, flushing and fatigue.
  • There is a lack of consensus whether foods high in histamine make this situation worse.
  • There is a lack of evidence on whether avoiding histamine in the diet works for patients with post-COVID syndrome.
  • There are anecdotal reports that it can improve symptoms which may mean some patients may wish to try it.
  • Anyone interested in trialling a low histamine diet, should not follow it for more than four weeks without the support of a registered dietitian 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 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.

Using the Patients Association nutrition checklist
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):

  • 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, or eating recommended foods, meals, snacks etc)
  • Body weight through subjective observations (e.g. visible gain of muscle or fat mass, fit of clothes, belts, watches etc)
  • Hand grip strength (muscle strength, but a dynamometer is needed).

If it is possible to weigh patients, screen for malnutrition risk using the ‘MUST’ to monitor patients (Lawrence et al., 2021).

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 (Barazzoni et al., 2020) on energy, macronutrient and micronutrient distribution.

Energy requirements (Barazzoni et al., 2020; Brugliera et al., 2020)

  • 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 (Barazzoni et al., 2020). High quality protein intake should be higher than 0.75 g/kg body weight, particularly for older adults given that many of them were shielding during lockdowns. It also may be that after these periods, supplementation may be necessary especially for vulnerable populations (Butler et al., 2020). Follow the food first approach and fortification when necessary first.
  • Fat and carbohydrate ratio 30:70 when no respiratory deficiency. From the first phase of rehabilitation, it is preferable to restrict carbohydrates to decrease respiratory failure and carbon dioxide accumulation (Aytür et al., 2020).
  • From the early recovery phase and when symptoms are still present and perhaps mild, patient should have adequate fluid intake as well as high fibre content in diet (Aytür et al., 2020) to support gut microbiota and in turn attenuating pulmonary inflammation (Hanson et al., 2016).

Micronutrients

  • Vitamin D requires specific attention, particularly with lack of sun in the winter (10 micrograms (400 International units) per day are recommended) (Cawood et al., 2020). Vitamin D supplementation in countries such as the UK has shown to be safe, and some data shows it may protect against acute respiratory tract infection (Naidu, Pressman and Clemens, 2021). The relationship between vitamin D and mortality due to COVID-19 has shown to be moderate to low quality in a systematic review. Many studies only included patients who were critically ill, therefore this does not take into consideration patients who were never hospitalised (Bassatne et al., 2021). The role of vitamin D for COVID-19 recovery is currently on debate in the UK parliament (Naidu, Pressman and Clemens, 2021).
  • Daily allowances for vitamins and trace elements (particularly A,D, E, B6 and B12, Ca, Zn and Se) should be ensured for malnourished patients at risk of or with COVID-19 (Aytür et al., 2020; Barazzoni et al., 2020). Intakes higher than reference nutrient intakes may be advantageous, however, excessive intakes of some of these nutrients are excreted, and if the intake is too high it may have a detrimental effect on immune function (for instance copper and zinc) (Lockyer, 2020).

Notes

  • If malnutrition is identified, follow NICE guidelines, ACBS (Advisory Committee on Borderline Substances) indications can support strategies (NHS, 2020).
  • In any case, aim to include practical suggestions for meals and snacks, deal with symptoms such as fatigue, nausea, or loss of taste (Cawood et al., 2020) as long as is not contradictory. Ensure adequate protein, vitamin and mineral intakes are achieved.
  • Breastfeeding should continue given data suggests that this confers enhanced immunity against viruses and harmful bacteria (Ayseli et al., 2020).
  • 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 (NHS, 2020).
  • Use food recalls to decide if further tests are needed to measure vitamin levels (Lawrence et al., 2021).

Importance of achieving adequate micronutrients levels
  • Vitamin C: doses above 200 mg/day are unlikely to benefit healthy individuals.
  • 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 help prevent infection from RNA viruses, such as influenza and coronaviruses, however many studies have been in vitro experiments (Patel, Martindale and McClave, 2020), not in humans. Zinc appears to have a role in preventing cytokine storm (Naidu, Pressman and Clemens, 2021) Learn more on the underlying mechanisms page.
  • 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 antioxidant activity and inhibits release of inflammatory cytokines. The development of low calcium and magnesium needs to be monitored for in persons with COVID-19.

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:

  • Withania somnifera, also commonly known as: ashwagandha, Indian ginseng, Indian winter cherry.
  • Tinospora cordifolia, also commonly known as: gulvel.
  • Panax ginseng, also commonly known as: Asiatic ginseng, Chinese ginseng, five fingers, Japanese ginseng, jintsam.
  • Emblica officinalis, also commonly known as: amla.
  • Echinacea perpurea, also commonly known as: purple coneflower, sampson, snakeroot, red sunflower.
  • Ocimum tenuiflorum, synonym: ocimum sanctum.
  • Uncaria tomentosa, also commonly known as: cat’s claw, una de gato.
  • Azadirachta indica.
  • Aloe barbadensis, also commonly known as: aloe vera.
  • Curcuma longa, also commonly known as: turmeric.
  • Zingiber officinale, also commonly known as: adarak, ginger.


Enteral or parenteral nutrition

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.

Contact us

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.

References

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.

Why we created this page
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

  • 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.