By Harriet Smith, RD and Elaine Anderson, RD
Long-COVID is becoming increasingly recognised both in the medical world and the media. The National Institute for Healthcare Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN) and the Royal College of General Practitioners (RCGP) are currently working on guidelines for its management, which are due to be released by the end of the year (1).
Long-COVID is also referred to as ‘Post-COVID Syndrome’ and it is defined as “symptoms that develop during or following an infection consistent with COVID, continue for more than 12 weeks and are not explained by an alternative diagnosis” (2). These symptoms can include fatigue, headaches, cough, loss of taste and smell, sore throat, delirium, muscle aches, breathlessness, chest heaviness or pressure, palpitations, as well as skin rashes and gastrointestinal problems.
The UK COVID Symptom Study app has collected data from over four million people and suggests that 1 in 20 are likely to suffer from symptoms lasting longer than 8 weeks (3). This article explores nutritional considerations for Long-COVID from a dietitian’s personal and professional perspective.
A Dietitian’s Personal Experience of Long-COVID
Elaine Anderson is a Registered Dietitian working in clinical practice. She says: “My journey began a few days before I tested positive for COVID on the 28th of April. My initial symptoms included fatigue, cough, temperature, sinus pain and extreme body aches. A few weeks later, I began having debilitating daily headaches and facial pain. I lost my taste and smell for about 10 weeks, which affected my appetite.
I was lucky that I could still eat and drink, and being a dietitian, I realised the importance of nutrition in my recovery. I also suffered with heart palpitations which resulted in several tests including an echocardiogram, electrocardiogram and cardiac MRI. These tests came back normal, however I have pursued further investigations because I have continued to suffer with both headaches and palpitations over the past 7 months - I am awaiting my results.
Through my interactions with other Long-COVID patients, it is clear that many of us are desperately seeking an improvement in our symptoms and are willing to try different dietary and lifestyle approaches.”
This section refers to hospital patients who were initially admitted to hospital with COVID-19 and have remained in an acute hospital setting for more than 12 weeks.
Optimal nutrition is vital following any illness, including COVID. Malnutrition is a significant problem amongst patients undergoing a long hospital admission. Some COVID patients may present on admission with malnutrition due to comorbidities. Additionally, previously healthy patients may be at increased risk of malnutrition during their admission due to a decline in nutritional intake pre-admission and secondary to the effects of the virus (4).
For example, patients with COVID are likely to have increased energy and protein requirements (5). Breathlessness and fatigue can lead to decreased oral dietary intake, which can be exacerbated due to a dry mouth (secondary to oxygen therapy) and/or pyrexia. Therefore, it is important to optimise nutritional status in hospital patients with Long-COVID.
A food-first approach should be used, where indicated. This may include (6):
- Offering high-energy, high-protein menu options
- Encouraging the patient to eat little and often
- Offering nourishing drinks
- Providing additional snacks
- Fortifying meals with energy-dense ingredients such as butter, cheese and oil
If oral dietary intake remains insufficient, Oral Nutritional Supplements (ONS) may be required to meet the patient’s nutritional requirements.
Seriously ill COVID patients who were unable to breathe unaided may have required a tracheostomy tube attached to a ventilator during their admission to the Intensive Care Unit (ICU). It is not uncommon for patients to develop dysphagia post-tracheostomy; this may require assessment and input from a speech and language therapist as well as texture-modified dietary support from a dietitian (4).
It is also important to assess and monitor for pressure ulcer wounds in patients who have a long-stay hospital admission. There have been anecdotal reports from healthcare professionals (HCPs) of pressure ulcers occurring on the sternum and hip bones of Long-COVID patients, due to them being nursed in a prone position (7). Individuals at risk/with chronic wounds should be screened for malnutrition using an appropriate, validated screening tool, and/or have a full nutrition assessment. For patients with chronic wounds, nutritional plans should ensure that adequate calories, protein, fluids, vitamins and minerals are provided (8).
It is important to consider barriers to eating well in hospitals during the pandemic. For example, many hospitals are experiencing reduced mealtime volunteers, lack of visitors, and less mealtime support from HCPs for patients due to strict social distancing guidelines and limited personal protective equipment (PPE). Some hospitals are operating with reduced catering facilities, meaning limited menu options. These factors can influence a patient’s oral nutritional intake and must be considered (9). Enteral tube feeding should be considered if a patient’s oral intake is negligible for more than 3 days, or predicted to be less than 50% of estimated nutritional requirements for more than 5-7 days (5, 10).
The government has recently announced the opening of 40 Long-COVID Clinics to help manage Long-COVID patients in the community (11). NHS England’s guidance document states that there will be a multidisciplinary approach in these clinics and that dietitians should be included as part of the team (12). The need for ongoing nutritional support for hospitalised and non-hospitalised Long-COVID patients will place an increased demand on primary care services (7). It is hoped that these clinics may help to reduce the burden on these services.
As with hospitalised patients, loss of taste and smell can occur in community-dwelling Long-COVID patients, regardless of the severity of their initial infection (13). Guidance such as using strong flavours and experimenting with different temperatures of foods may be useful. You can read more about eating well with loss of taste and smellhere.
Interestingly, there have been several case reports of Long-COVID patients being diagnosed with postural tachycardia syndrome (POTS) (14,15). This is a form of dysautonomia; a dysfunction of the autonomic nervous system which causes symptoms such as dizziness, fainting and fatigue. Although there is no cure for POTS, dietary and lifestyle modifications can help alongside medications. The charity POTS UK suggests aiming for at least 2-3 litres of fluid daily and increasing salt intake (16), however it is worth noting extra salt should only be taken after consulting with a doctor.
It has been suggested that Mast Cell Activation Syndrome (MCAS) may also contribute towards Long-COVID symptoms (17). MCAS occurs when the mast cells release too much of the substances inside them at the wrong times. There has been much discussion regarding the role of a low histamine diet in managing Long-COVID symptoms related to MCAS. Histamine is one of the inflammatory chemicals released by mast cells; it has been suggested that a low histamine diet could reduce overall histamine in the body, thereby improving symptoms (18). However, further research is required.
Dietitians play a crucial role in the treatment and management of Long-COVID patients both in an acute and community setting. It is important for HCPs to provide evidence-based nutritional advice and care, whilst recognising and respecting their patients’ decision to seek out alternative treatments and dietary approaches. Further research is required into the dietary management of Long-COVID patients.
National Institute for Health Care And Excellence NICE & SIGN announce latest rapid Covid-19 guideline will address Long Covid. 2020 Available from:NICE & SIGN announce latest rapid Covid-19 guideline will address Long Covid | News and features | News | NICE
NICE, SIGN & RCGP. COVID-19 guideline scope: management of the long-term effects of COVID-19. October 2020. Available from:final-scope (nice.org.uk)
Zoe. Covid Symptom Study. One in 20 people likely to suffer from ‘Long COVID’, but who are they? October 2020 Available from:One in 20 people likely to suffer from ‘Long COVID’, but who are they? (joinzoe.com)
British Dietetic Association. Practical considerations for nutritional management of non-ICU COVID-19 patients in hospital. May 2020, Version 1. Available from:Practical considerations for nutritional management of non-ICU COVID-19 patients in hospital (bda.uk.com)
Nutrition Management for Critically and Acutely Unwell Hospitalised Patients with COVID-19 in Australia and New Zealand Australasian Society of Parenteral and Enteral Nutrition. April 2020, Version 1. Available from:https://custom.cvent.com/FE8ADE3646EB4896BCEA8239F12DC577/files/93ecb5eadf7244faa98d9848921428a8.pdf
NHS. Royal Devon and Exeter NHS Foundation Trust. A Guide to Eating Well with a Respiratory Disorder. May 2020. Available at:https://www.bda.uk.com/uploads/assets/5bb3755b-de6e-4da0-ba7b63b1624ea259/bd87d957-6d15-4140-9c5153b5d10b9926/Patient-information-leaflet-guide-to-eating-well-with-respiratory-disorder.pdf
NHS England.After-care needs of inpatients recovering from COVID-19. June 2020, Version 1. Available from:nhs-aftercarecovid.pdf (pcrs-uk.org)
- Munoz N, Posthauer ME, Cereda E, Schols JMGA, Haesler E. The Role of Nutrition for Pressure Injury Prevention and Healing: The 2019 International Clinical Practice Guideline Recommendations. Adv Ski Wound Care. 2020;33(3):123–36.
National Nutrition Nurses Group. Practical Advice and Guidance for management of nutritional support during COVID-19.April 2020,Version 2. Available from: https://www.nnng.org.uk/2020/04/covid-19-statement-and-information
Barazzoni R et al. ESPEN expert statements and practical guidance for nutritional management of individuals with sars-cov-2 infection, Clinical Nutrition Editorial. 2020; P1631- 1638 Volume 39, Issue 6. Available from:https://doi.org/10.1016/j.clnu.2020.03.022
NHS England. NHS launches 40 ‘long COVID’ clinics to tackle persistent symptoms. November 2020. Available from:NHS England » NHS launches 40 ‘long COVID’ clinics to tackle persistent symptoms
NHS England National Guidance for post-COVID syndrome assessment clinics 2020 Available from:Report template - NHSI website (england.nhs.uk)
Lechien, J.R., Chiesa-Estomba, C.M., De Siati, D.R. et al. Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study. Eur Arch Otorhinolaryngol.2020; 277:2251–2261 Available from:https://doi.org/10.1007/s00405-020-05965-1
Miglis, M.G., Prieto, T., Shaik, R. et al. A case report of postural tachycardia syndrome after COVID-19. Clin Auton Res.2020;30: 449–451.https://doi.org/10.1007/s10286-020-00727-9
Dani et al. Autonomic dysfunction in ‘long COVID’: rationale, physiology and management strategies Clinical Medicine. November 2020. Available from:https://doi.org/10.7861/clinmed.2020-0896
PoTS UK. Diet and Fluids. August 2020. Available from:PoTS - Postural Tachycardia Syndrome (potsuk.org)
- Afrin, L. B., Weinstock, L. B., & Molderings, G. J. Covid-19 hyperinflammation and post-Covid-19 illness may be rooted in mast cell activation syndrome. International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases. 2020; 100: 327–332.
- Maintz L, Novak N Histamine and histamine intolerance. Am J Clin Nutr.2007; 85(5): 1185-1196.