Managing symptoms linked to nutrition during COVID-19 recovery

Information to help professionals manage patient symptoms linked to nutrition

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 (Gem COVID, 2020; NHS, 2020; NICE, 2020; Davis et al., 2021; NIHR, 2021; Wise, 2021).

Watch nutrition scientist, Dr Sarah Berry, discussing how to manage post-COVID syndrome related symptoms from a nutritional perspective – Diet and COVID on our Nutrition and COVID-19 Recovery page.

Currently there is a new Long Covid symptom burden questionnaire, which is undergoing further development. See here for more info: https://www.bmj.com/content/377/bmj-2022-070230

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.

View more information about the mechanism of COVID-19 symptoms.

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 the individual from eating the energy or nutrients required.
  • Decreased activity endurance may prevent a person from 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).
  • These side effects can make people feel anxious about eating in front of others which may create relational difficulties in the home environment.
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 the person to lose essential nutrients and therefore adjustments are needed regarding diet.
  • This website explains in plain English why smell or taste loss happens and the underlying mechanisms of this: https://www.fifthsense.org.uk/
  • A diminished or lost sense of taste makes it more difficult for people to appreciate and enjoy eating, causing them to avoid many foods. This can in return associate with anxiety and depression. A diminished threshold for salt perception may cause people to increase their discretionary salt intake to improve food palatability, increasing their risk of cardiovascular disease. This is why checking labels is important and find foods that can add flavour without an excessive amount of salt (Risso, Drayna and Morini, 2020).
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.
  • Adjusting to changed health status and having a long-term condition can lead to depression and anxiety disorders (NIHR, 2021).
  • Sleeping disturbances such as short or interrupted sleep have been associated with increased inflammation, reduced functional capacity to fight infections (Lockyer, 2020).
Useful links to address some of these symptoms

Functional, social and occupational effects
Symptoms
  • Low work productivity
  • Inability to undertake normal activities of daily living
  • Mobility and self care issues
  • Food poverty
What does it have to do with the patient’s nutrition and diet?
  • Not meeting protein and vitamin requirements may trigger feeling tired at work.
  • Working patterns have been reported to be impaired by Long COVID and people were reported to have financial constraints (NIHR, 2021). Limiting daily living activities can impact access to nutritious food which can decrease variety in patient’s diet, preventing them from receiving all nutrients and calories they are used to.
  • In the US, ethnic minorities are widely affected by COVID-19. Groups such as the elderly or ill are less likely to have access to fresh foods, due to not having availability or ability to obtain transportation to grocery stores. Urban occupants, especially, may live in food deserts where their geographics – distance from farms or gardens with fresh harvests – limit them from accessing healthy and nutritional foods (Polamarasetti and Martirosyan, 2020).
  • Findings from the ZOE App (Merino et al., 2021) suggest that high diet quality is associated with lower risk of COVID-19 and severe COVID-19. This relationship seems more pronounced in communities with higher socioeconomic deprivation.
Useful links to address some of these symptoms

Metabolic associated problems
  • Obesity
  • Diabetes
  • High blood pressure
  • Heart disease
  • Sedentarism (due to lockdowns, shielding or other reasons)
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 for further guidance
  • Practising yoga has been found to decrease various proinflammatory markers, especially practised in long time spans, therefore improving cardio-metabolic health (Khoramipour et al., 2021)
  • A medium quality paper reviewed a myriad types of exercise under different clinical conditions and discussed guidelines to be used by patients with long COVID (Khoramipour et al., 2021)
  • This document (Killerby et al., 2020) presents an example of a triage program to manage incoming patients however it touches more on risk of people with underlying conditions to be hospitalised
  • Physical activity or exercise should be personalised and overseen by a physiotherapist or occupational therapist with specialist training and expertise. A clinical review should be undertaken after each session, especially when exercise is used as a rehabilitation tool (NIHR, 2021).
  • Monitoring patients during their COVID-19 recovery
  • Assessing nutritional needs and setting realistic goals
Physical activity for older adults
Increases in physical activity can become integrated into daily life. This may mean a ‘triage’ type system locally that knows all the available services in the area (online, face to face, evidence-based falls prevention and more health promotion strength and balance sessions). Those at highest risk of falls should be seen by a multi-disciplinary team and offered evidence-based falls prevention programmes (for example, FaME (Falls Management Exercise) and Otago) delivered by appropriately qualified individuals (Physiotherapists, trained rehabilitation assistants, Postural Stability Instructors and Otago Exercise Programme Leaders). Others, who have not transitioned into frailty but need to work on their strength and balance so they are confident in increasing their general physical activity, can be directed to community-based face to face and online options delivered by Personal Trainers and other qualified exercise instructors. For individuals with long-term conditions, increasing physical activity from levels seen during the pandemic should be considered as part of a general approach to supporting individuals to manage their own conditions. Finally, it is important to note some of the differences in activity levels between different groups of older adults, with the largest reductions in physical activity seen in males aged 65 to 74, and females aged 65 to 84 – suggesting that efforts aimed at encouraging resumption of past physical activity should be particularly focussed upon these groups. Some apps and websites have been scientifically analysed and peer reviewed, thus recommended for more active older adults (article can be found in link https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-020-01880-6). Many organisations recommend ‘Make Movement Your Mission’ which runs 15 minute movement ‘snacks’ 3 times a day, 7 days a week on Facebook and YouTube. It is important to consider the functional levels of the individual and signpost to the most appropriate local or online programmes available.

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 (Malnutrition Pathway, 2020). Symptoms such as anosmia, dysgeusia (loss/alteration of taste) or diarrhoea or a combination of these increase risk of disease-related malnutrition (Ballesteros Pomar and Bretón Lesmes, 2020). There is a fundamental difference between symptoms related to post-viral chronic fatigue from those to traumatic stress disorder and those due to post critical illness.
Some authors (Sudre et al., 2020) characterised two patterns for long covid: people with fatigue, headache and upper respiratory complaints (shortness of breath, sore throat, persistent cough and loss of smell) and/or people with additional multi-system complaints, including ongoing fever and gastroenterological symptoms. Other studies suggest that in some cases symptoms relate to a pre-existing health condition or disability (NIHR, 2021).
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:

Resources to support food and symptom tracking

Symptoms of post-COVID syndrome
Post-COVID syndrome is defined as symptoms persisting 12 weeks or more after the onset of the first symptom (NICE, 2020). Although lungs are considered the main target organ of COVID-19, the virus can affect many other organs, including the heart, blood vessels, kidneys, the digestive tract and the brain, through other mechanisms (Gem COVID, 2020). For example, gut symptoms and fatigue may be associated with the psychological and physical processes of having suffered COVID-19. Coordinated care, multidisciplinary work, referral pathways and management according to symptoms have been referred as priorities across the UK (B Balbi et al., 2020). On first contact, when symptoms are discussed, clinicians should run a differential diagnosis to confirm whether these symptoms are associated with post COVID syndrome.
Symptoms of ongoing and post COVID-19 syndrome (Davis, H.E. et al., 2021; NICE, 2020), which are related to nutrition, are:
  • systemic and musculoskeletal: fatigue, post-exertional malaise and pain
  • neuropsychiatric: sleep disturbance, dizziness, low mood and anxiety
  • gastrointestinal: nausea, diarrhoea, anorexia and reduced appetite
  • cardiovascular: breathlessness, myalgia and cough – myocardial injury is the most common complication, thus self-monitoring blood pressure and pulse oximetry may help
  • genitourinary and endocrine: liver dysfunction and symptoms related to urinary function. Low and high blood glucose levels may also be common
While some people may experience symptoms similar to CFS, because is new, we cannot assume that CFS symptoms alleviation will definitely work for post COVID syndrome.
Further information and access to a screening tool for nutritional issue in post-COVID syndrome can be found:

COVID-19 related symptoms
The following list provides an approximate prevalence of symptoms that are included in the symptom toolkit 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 detriment due to 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 and chest pain (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 post-COVID syndromecan 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 post-COVID syndrome 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.

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

B Balbi et al. (2020) ‘Report of an ad-hoc international task force to develop an expert-based opinion on early and short-term rehabilitative interventions (after the acute hospital setting) in COVID-19 survivors (version April 3, 2020).’ doi: https://ers.app.box.com/s/npzkvigtl4w3pb0vbsth4y0fxe7ae9z9 [accessed 25.05. 20].

Ballesteros Pomar, M.D. and Bretón Lesmes, I. (2020) ‘Clinical Nutrition in times of COVID-19’, Endocrinología, Diabetes y Nutrición (English ed.), 67(7), pp. 427–430. doi:10.1016/j.endien.2020.09.004.

Davis, H.E. et al. (2021) ‘Characterizing Long COVID in an International Cohort: 7 Months of Symptoms and Their Impact’, medRxiv, p. 2020.12.24.20248802. doi:10.1101/2020.12.24.20248802.

Gem COVID (2020) ‘Post-COVID-19 global health strategies: the need for an interdisciplinary approach’, Aging Clinical and Experimental Research, pp. 1–8. doi:10.1007/s40520-020-01616-x.

Khoramipour, K. et al. (2021) ‘Physical activity and nutrition guidelines to help with the fight against COVID-19’, Journal of Sports Sciences, 39(1), pp. 101–107. doi:10.1080/02640414.2020.1807089.

Killerby, M.E. et al. (2020) ‘Characteristics Associated with Hospitalization Among Patients with COVID-19 — Metropolitan Atlanta, Georgia, March–April 2020’, Morbidity and Mortality Weekly Report, 69(25), pp. 790–794. doi:10.15585/mmwr.mm6925e1.

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.

Malnutrition Pathway (2020) ‘A Community Healthcare Professional Guide to the Nutritional Management of Patients During and After COVID-19 Illness’, p. 9.

Merino, J. et al. (2021) ‘Diet quality and risk and severity of COVID-19: a prospective cohort study’, Gut, 70(11), pp. 2096–2104. doi:10.1136/gutjnl-2021-325353.

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.

NIHR (2021) Living with Covid19 – Second review, NIHR Evidence. doi:10.3310/themedreview_45225.

NIHR, E. (2021) Living with Covid19 - webinars - Informative and accessible health and- care research. Available at: https://evidence.nihr.ac.uk/themedreview/living-with-covid19-webinars/?source=chainmail (Accessed: 26 April 2021).

Polamarasetti, P. and Martirosyan, D. (2020) ‘Dietary Deficiencies Exacerbate Disparity in COVID-19 and Nutrition Recommendations for Vulnerable Populations’, Bioactive Compounds in Health and Disease, 3(11), pp. 204–213. doi:10.31989/bchd.v3i11.759.

Risso, D., Drayna, D. and Morini, G. (2020) ‘Alteration, Reduction and Taste Loss: Main Causes and Potential Implications on Dietary Habits’, Nutrients, 12(11), p. 3284. doi:10.3390/nu12113284.

SCCM (no date) SCCM | Long Term Neurological Complications of COVID-19, Society of Critical Care Medicine (SCCM). Available at: https://sccm.org/COVID19RapidResources/Resources/Long-Term-Neurological Complications-of-COVID-19 (Accessed: 16 March 2022).

Sudre, C.H. et al. (2020) Attributes and predictors of Long-COVID: analysis of COVID cases and their symptoms collected by the Covid Symptoms Study App, p. 2020.10.19.20214494. doi:10.1101/2020.10.19.20214494.

Wise, J. (2021) ‘Long covid: WHO calls on countries to offer patients more rehabilitation’, BMJ, 372, p. n405. doi:10.1136/bmj.n405.

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

  • Healthcare professionals require a professional toolkit to assist them in supporting patients effectively. The toolkit should outline the range of potential symptoms and scenarios to allow healthcare professionals to select and combine management strategies based on patient needs, situation and barriers.
  • Patients in our study wanted 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 patient-centred goals, as well as support symptom management.