Advanced dietary advice should usually be provided by a nutrition expert such as a dietitian or healthcare professionals who have had appropriate training. Such advice is summarised below but does not replace advice from an expert.
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; look out 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).
Fluid
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
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 show 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 been shown to be of 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).
Other vitamins
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).