How can we implement effective strategies to alleviate and support long-COVID?
With the so-called curse of “Long-COVID” estimated to affect a third of people post-infection, the legacy of this virus is set to disrupt populations for years to come. It is still unclear as to why some people experience the virus more, or less, severely, and why prolonged symptoms linger in some but not in others.
Inevitably there are still more questions than answers as the studies play catch-up with the reality of people living their lives blighted by persistent symptoms. Dubbed as ‘long-haulers’ these people are now seeking therapeutic strategies to alleviate and support long-COVID symptoms in a bid to get back to full health as quickly as possible. How can an already overloaded healthcare system support these individuals?
BANT Fellow, Registered Nutritional Therapy Practitioner, Consultant in genomic medicine and Clinician at the University of Stirling, Anh Nguyen, walks us through the latest research and nutritional considerations for supporting long-haulers, raising the question as to why Registered Nutritional Therapy Practitioners are not yet being considered part of the longer-term solution.
What is the definition of, and characteristics of long-COVID?
“Almost 5 months post-COVID I have little to no taste or sense of smell and lack of appetite. I am extremely lethargic throughout the day and everyday tasks seem to be very difficult. I was active and healthy before.” Mona, Birmingham, UK recalling her symptoms
Studies estimate that up to one-third of people post-COVID, like Mona, have been suffering from a new disease which can last anywhere between a month to a year, and beyond. Scientists named this disease post-acute sequelae of COVID-19 (PASC), or commonly described as “Long-COVID”. A systematic review of 45 studies1, consisting of 10,000 patients and 84 discrete symptoms, found that nearly three-quarters of patients reported at least one persistent symptom for a mean or median of 2 to 4 months, and some symptoms were reported to persist for as long as 6 to 8 months. A survey on 3,065 British children age between 11 and 17 demonstrated that 14% of children were still experiencing symptoms 15 weeks post-COVID 2. Similarly, a recent report of The UK Office for National Statistics surveyed half a million children with COVID, found that 12.9% and 14.5% of children aged between 2-11 and 12—16 respectively were still experiencing COVID symptoms five weeks after their first infection3.
Why do some patients experience Long-COVID and others do not?
All humans have 99.9% identical DNA sequences across the estimated 6 billion-letter code for their genome. Slight differences (0.1%) exist between individuals, making each of us unique. These differences, called genomic variants, occur at specific locations within the DNA. These variants can increase the risk of developing diseases, while others may reduce such risk; and some may have no effect on disease risk. To date, it is not exactly known why some patients have long-COVID symptoms, but others do not, and studies are ongoing. Epidemiological studies have revealed women are more likely to have long-COVID than men. Moreover, long COVID is significantly associated with increasing age, particularly age 40 and over. Additionally, the REACT findings4 emphasised there is a 3.5% increase in likelihood in each decade of life. Other clinical risk factors are obesity, smoking, and pre-pandemic health conditions.
Seeking the Root Causes of Long-COVID Symptoms
Scientists believe that long-COVID symptoms might be a consequence of lingering inflammatory process following SARS-CoV-2 infection5. Another possible mechanism in relation to COVID-post symptoms is “molecular mimicry”, which may induce autoimmunity6. Together or alone, such inflammations or other yet unknown mechanisms might affect a variety of body systems and lead to different symptoms among COVID-long-haulers.
However, few studies pay attention to diet and lifestyle factors that might contribute to this process as well as prevent an ability to recover from long-COVID symptoms.
Nutritional therapy strategies to support long-COVID
With numbers of long-haulers continually growing, there is an urgent need for a strategy focusing on diet and nutrition that addresses long-COVID symptoms. We conducted a search of literature (*search criteria at end) focusing on long COVID and nutrition and our findings found that three nutrition therapeutic strategies may support long-COVID.
Strategy 1 – Food Choices
The first strategy aims to lower the hyper-inflammatory process. In this stage, we take a small step to switch from inflammatory food patterns to less inflammatory ones, whilst ensuring the body gets all nutrients it needs. Evidence7 shows post-COVID patients prolonged the inflammatory state up to 2 months since the infection began. Plant-based diets are proven to display anti-inflammatory effects, and may include a variety of vegetables, fruits, nuts, seeds, legumes. Storz (2021) also emphasised that some common long-COVID symptoms such as fatigue, muscle and joint pain, sleep disorders may benefit from plant-based diets8. For example, plant foods can provide dietary fibre that is not typically prevalent in Western diets. Lack of dietary fibre is strongly associated with hyper-inflammatory state-related conditions. Cognition and memory impairments in long-haulers, commonly described as “brain fog” might be related to post-viral gut dysbiosis. To support this hypothesis, our recent data found that the SARS-CO-V2 virus might affect the gut microbiome in infected patients when compared with healthy people and the altered microbiome could not return to stable levels for up to 6 months.9 As a result, this may affect the connection between the brain and gut and the digestive function.10
Plant foods also provide good sources of phytochemicals and antioxidants. These “natural agents” can eliminate free radicals and relieve the inflammatory process in relation to potential multiple organ damage caused by long-COVID. Increasing intake of plant foods such as fruit and vegetables may increase levels of micronutrients as well. Following a partial or predominant plant-based diet does not require complete elimination of animal proteins. Sources such as chicken, egg, and fish are important for the essential amino acids, iron and vitamin B12 that we need. Additionally, oily fish such as sardines and salmon are rich in omega-3 fatty acids DHA and EPA. Omega-3s are anti-inflammatory and help support the normal function of the brain, particularly cognition and memory.
Strategy 2 – Mindful Eating & Retraining Olfactory & Gustatory senses
The second strategy aims to connect the body’s hunger and satiety signals to improve appetite and food intake. The impairments in hunger and satiety sensations may be a consequence of COVID-induced loss of taste and smell. The practise of mindful eating can help an individual achieve full attention to sensory perceptions while eating. Moreover, it can increase pleasure eating as well as an awareness of hunger and fullness signals11, 12.
There are some steps to practicing mindful eating that might help long-haulers re-activate loss of taste and smell in a purposeful manner:
- Carefully select ingredients and prepare your meal.
- Sit at the table and focus on eating, no phone or TV interruption
- Wake up all senses while eating by looking at your meal, smelling your meal, and chewing slowly and mindfully.
- Take one small bite at a time and focus on the food from first bite through to swallowing.
- Avoid skipping meals.
Strategy 3 – Additional Food Supplement support
The third strategy looks at supplements** that may support long-COVID symptoms (**see disclaimer below). Some dietary supplements such as vitamin D, vitamin C, and Zinc were highly considered to support the immune system in fighting COVID-19 and now are thought to help with some long-COVID symptoms. Few primary studies to date have examined the effect of micronutrients and probiotics on fatigue, memory and cognitive dysfunction among people with long-COVID but we have shared a couple below.
Vitamin D supports the immune system and can help regulate anti-inflammatory responses by inhibiting pro-inflammatory pathways including cytokine storm that was well-reported in COVID infections. Thus, vitamin D may be a beneficial addition, particularly during winter when sunlight is limited or for individuals in whom deficiency is suspected or confirmed. A systematic review and meta-analysis found that being overweight or obese is a factor known to increase the risk of vitamin D deficiency, regardless of age and location13.
In a study14 led by Rossato (2021), around 200 people with persisting fatigue symptoms (>4 weeks) post onset of the acute phase of their COVID were supplemented with magnesium, iron, Vitamin B3, Vitamin C, and Panax ginseng extract. As a result, 76.62% and 90.05% of participants improved their fatigue symptoms after 2 weeks and 4 weeks of the intervention, respectively (p<0.05).
A randomised controlled trial (RCT)16 using probiotics with strains of Bacillus in combination with systemic enzymes including bromelain demonstrated that 91% of participants in intervention groups improved fatigue symptoms in the 14-day intervention period, compared to 15% of people in the control group (Rathi et al. 2021).
With one-third of people post-COVID suffering symptoms of long-COVID the healthcare system is lacking the resources and manpower to support them all. Long-haulers need implementable dietary and lifestyle therapeutic protocols and a dedicated workforce of practitioners to help take the strain. The field of personalised nutrition is still evolving before truly becoming an integral part of the future healthcare paradigm. However current voluntary regulation of the nutritional therapy profession with the CNHC which is a PSA accredited organisation, a body accountable to Parliament. This registration is recognised by many healthcare professionals and already in 2015 General Medical Council (GMC) made an amendment to their guidelines saying: '...... be satisfied that systems are in place to assure the safety and quality of care provided – for example, the services have been commissioned through an NHS commissioning process or the practitioner is on a register accredited by the Professional Standards Authority'. Simply put, Registered Nutritional Therapy Practitioners have a role to play.
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