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Galore International Journal of Health Sciences and Research
Vol.5; Issue: 3; July-Sept. 2020
Website: www.gijhsr.com
Short Communication P-ISSN: 2456-9321
Fasten the Nutrients!! Flatten the Pandemic!! -
Core Contribution of Medical Nutrition Therapy in
COVID-19
V. Bhavani
Dietician, ESIC Medical College and Hospital, KK Nagar, Chennai
ABSTRACT sufficient sleep, with good life style habits help
in sound mind and healthy body leading to
Currently the whole World in one perspective disease free life.
fighting against the new pandemic situation rose
due to prevalence of Covid-19. Lot of Keywords: COVID-19, Coronavirus, Nutrition,
researches is evolving about the role of Medical Nutrition Therapy
Nutrition in Covid-19. Even though there is no
consistent data supporting the direct role of INTRODUCTION
Nutrition in Covid-19, there are many research Adequate and appropriate nutrition
across the world proved that many nutrients is required for all cells to function
plays a vital role in betterment of the condition optimally. This includes the cells in the
by improving the immunity. Nutrition is a
immune system too. The immune system
science required for a healthy life. The present
research paper explored about Medical Nutrition demands for energy and nutrients. This can
Therapy among Covid-19 patients and the role be met from exogenous sources such as the
of various nutrients in boosting up the immunity diet, or from endogenous sources such as
and preventing the respiratory infections. body stores. Some micronutrients and
Medical Nutrition Therapy is a branch of Life dietary components have very specific roles
Science which helps in Patient Management. in the development and maintenance of an
Nutritional assessment tools such as R-MAPP: effective immune system throughout the life
Remote Malnutrition in Primary Practice and course or in reducing chronic inflammation.
Eat-10 questionnaires are used among Covid-19 World Health Organization (WHO), 2020,
patients. Micro nutrients like Vitamin A, C, D, states that “viral infections are one of the
E, Selenium, Iron, Zinc are reported to act
world’s greatest public health challenges”.
against respiratory Infections. These are
immune Nutrients which is said to have anti The WHO guidance on diet, especially
viral properties. Consumption of these immune during the current pandemic states that
nutrients helps to protect from any respiratory “good nutrition is crucial for health,
infections. Proper hydration helps decrease particularly in times when the immune
nasal irritation when coughing, sneezing and system might need to fight back”1.
even just breathing. Traditional foods are nature According to The European Journal of
gift which are loaded with immense immune Clinical Nutrition, “Without adequate
nutrients and supports the well being. Multi nutrition, the immune system is clearly
Vitamin Tablets can be consumed with the deprived of the components needed to
prescription of the physician. Meditation/ yoga/ generate an effective immune response” 2.
Aerobics can be practiced regularly with
Good nutrition is thus important in
sufficient sleep for 7 to 8 hours per day. The
present study recommends “APP” to fight supporting an optimum immune system
against this pandemic situation: A- Adequate which can reduce the risk of viral
Nutrition, P-Physical Activity, P-Proper Sleep. infections3. Nutrition care is vital,
Well-balanced diet, periodic physical activity, particularly in patients with COVID-19
Galore International Journal of Health Sciences and Research (www.gijhsr.com) 30
Vol.5; Issue: 3; July-September 2020V. Bhavani. Fasten the nutrients!! flatten the pandemic!! - core contribution of medical nutrition therapy in
COVID-19
infections. Nutritional status and nutritional 27 kcal per kg body weight per day for
care plays a very relevant role in defining adults above 65 years with polymorbid
both short- and long-term outcomes of conditions
Covid -19 patients. 30 kcal per kg body weight per day for
severely under nourished, polymorbid
NUTRITIONAL ASSESSMENTS patients. Target should be reached
DURING COVID 19 cautiously and slowly due to high risk
Lei Zhang, 2020 insisted that Non-intubated ICU patients: If the
nutritional status of each covid -19 infected energy target is not reached with an oral
patient should be evaluated before the diet, Oral Nutritional Supplement (ONS)
administration of general treatments4.. should be considered first and then
R MAAP: is simple and rapid remote switch over to Enteral Nutrition (EN)
nutritional screening tool has been treatment. If there are limitations for the
developed exclusively for this covid 19 enteral route it could be advised to
pandemic. The acronym for the tool is prescribe peripheral Parenteral Nutrition
R-MAPP, as for Remote – (PN).
Malnutrition APP, while the tool is Energy administration: hypocaloric
being developed as an app. Since the nutrition, not exceeding 70 % of EE
tool is designed for the family should be administered in the early
physicians in the conditions of remote phase of acute illness with increments
patient care, it can also stand for Remote up to 80-100% after day 3. If predictive
– Malnutrition in the Primary Practice. equations are used to estimate the
This tool is used as a combination of energy need, hypocaloric nutrition < 70
MUST and SARC-F. The First three % estimated needs should be preferred
steps used in ‘MUST’ to assess the risk over isocaloric nutrition for the first
of malnutrition which includes (a) body week of ICU stay.
mass index (BMI), (b) unintentional Intubated ICU patients : In ICU patients
weight loss, and (c)acute disease effect who do not tolerate full dose EN during
is evaluated. Secondly, to assess the loss the first week, initiate parenteral
of muscle mass and functions, SARC-F nutrition (PN) 7
questionnaire can be used as a rapid
diagnostic test for sarcopenia. This is Protein:
based only on muscle contractile 1 g protein per kg body weight per day
performance items such as strength, in older persons. This is individually
assistance with walking, rise from a adjusted with regard to Nutritional
chair, climb stairs and falls5 .Based upon status, physical activity level, disease
the nutritional scores, Nutrition care status and tolerance
plan for the patients should be ≥ 1 g protein per kg body weight per day
prescribed tailored made. in polymorbid medical conditions. This
EAT-10: questionnaire is an easy is to prevent body weight loss, reduce
swallowing screening tool consisting of the risk of complications and hospital
ten questions that could also be included readmission and improve functional
in the remote evaluation of patients with outcome.
dysphagia6 Intubated ICU patients: During critical
illness, 1.3 g per kg body weight of
MACRO AND MICRO NUTRITIONAL protein equivalents per day can be
REQUIREMENTS delivered progressively7.
Energy:
30 kcal per kg body weight per day for Regular consumption of egg whites,
adults milk and milk products, dhals, nuts whey
Galore International Journal of Health Sciences and Research (www.gijhsr.com) 31
Vol.5; Issue: 3; July-September 2020V. Bhavani. Fasten the nutrients!! flatten the pandemic!! - core contribution of medical nutrition therapy in
COVID-19
water helps to improve the protein wheat bread, millets such as ragi, barley,
consumption. Covid-19 patients on High bajra rather than refined grain foods such as
protein liquid should be given milk, dhal white pasta and white bread.
water (well cooked, mashed and filtered Fluids: Water is part of every cell in the
dhal), whey water, nuts milk shake. body. When the body is sick with the flu or
Diseases specific Nutritional supplements any type of virus, there are common
can be recommended by Registered symptoms that can lead
Dietician .Based on the General guidelines, to dehydration including fever, cough,
the diet must be tailored made based on the diarrhea, vomiting and loss of appetite.
co-morbid conditions. When there is in sufficient fluids, body may
Fat and carbohydrates: adapted to energy have difficulty in regulating the
needs, fat-to-carbohydrate energy temperature. Even small fluid losses can
ratio 30:70 (no respiratory deficiency) to contribute to increased body temperatures.
50:50 percent (ventilated patients) 7 . Proper hydration helps decrease nasal
Non ICU patients and Non Covid irritation when coughing, sneezing and even
conditions: just breathing.
Sugars: WHO recommends that ideally Consumption of fluid is very essential.
only less than 5% of total energy intake for Consume fluids as buttermilk, clear soups,
adults should come from free sugars (about tender coconut water, rice water, barley
6 teaspoons). When other dessert options water, dhal water, whey water, fresh juice
are chosen, ensure that they are low in sugar without sugar, lemon juice with pinch of salt
and consume small portions. In case of and pepper, herbal tea, ‘panagam’, a
Diabetics, completely avoid sugary items traditional South Indian liquid made with
such as sugar beverages, sweets, squashes, plain water, jaggery and few drops of
pastries, bakery foods. lemon. Avoid drinking large amounts of
Sodium: WHO recommends consuming strong coffee, strong tea and carbonated
less than 5 g of salt per day. In order to beverages. These may lead to dehydration
achieve this, prioritize foods with reduced and can negatively impact sleeping patterns.
or no added salt. Consider rinsing canned Sipping hot water regularly helps to sooth
foods such as vegetables and beans, to the throat.
remove some of the excess sodium. Add Vitamin A: Vitamin A is also called
lemon juice and herbs to enhance taste and “anti‐infective”, and it acts as against
flavor. Avoid adding extra salt when infection depend on an adequate supply.
cooking and to your meals at the table. Semba et al had reported that vitamin A
Avoid consuming processed and preserved supplementation reduced morbidity and
such as pickles, pappads. mortality in different infectious diseases,
Fiber: Dietary fiber is defined as “the such as measles, diarrheal disease,
portion of food derived from the plant cells, measles‐related pneumonia, human
which is resistant to hydrolysis/ digestion by immunodeficiency virus (HIV) infection,
the elementary enzymes system in the and malaria8. Vitamin A is abundant in all
human being”. It consists of hemicellulose, colored vegetables and fruits like papaya,
cellulose, lignin, oligosaccharides, pectin, pumpkin, greens, oranges, tomato, carrot,
gums, and waxes. Fiber contributes to a mangos.
healthy digestive system and offers a Vitamin C: Vitamin C is best known for its
prolonged feeling of fullness, which helps antioxidant properties and support healthy
prevent overeating. To ensure an adequate immune function. This vitamin is water
fiber intake, aim to include vegetables, fruit, soluble and cannot be stored in the body.
pulses and wholegrain foods, greens in all The vital role of vitamin C involves in Iron
meals. Wholegrains foods include oats, absorption. It also benefits to increase WBC
brown pasta and rice, quinoa and whole- activity and platelets counts. That is the
Galore International Journal of Health Sciences and Research (www.gijhsr.com) 32
Vol.5; Issue: 3; July-September 2020V. Bhavani. Fasten the nutrients!! flatten the pandemic!! - core contribution of medical nutrition therapy in
COVID-19
reason we provide vitamin C rich foods Vitamin D: Vitamin D plays an essential
during dengue. Vitamin C is also given role in the immune system. Vitamin D
during common cold. During infection, inhibits the production of pro-inflammatory
vitamin C levels can become depleted and a cytokines and increases the production of
person’s requirement for vitamin C anti-inflammatory cytokines. In the
increases with the severity of the infection9. randomized trials and meta-
An Indian study, conducted in Chennai city analysis, vitamin D supplementation has
showed the deficient intake of Vitamin C been shown to have protective effects
consumption. It was observed that Vitamin against respiratory tract infections;
C consumption was less than the therefore, people who are at higher risk
recommended levels. The mean vitamin C of vitamin D deficiency during this global
intake was found to be 22 ±3.3 milligrams pandemic should consider taking vitamin D
in male and 24 ±3.8 milligrams in female supplements to maintain the circulating
whereas the recommended value is 40 25(OH)D in the optimal levels (75–125
milligrams per day 10. It is essential to meet nmol/L)12 .In Belgium, a retrospective
the requirements to boost the immunity. observational study consisted of 186
A meta-analysis of 18 controlled clinical positive cases and 2717 negative controls,
trials with a more than 2000 patients to reported a significant (p = 0.0016) low
evaluate the effect of vitamin C on length of median of vitamin D in COVID-19 patients
stay in the hospital ICU and the duration of compared to the control subjects 13. An
mechanical ventilation was performed. In 12 Indonesian retrospective cohort study
of the trials reviewed, length of ICU stay included 780 cases reported that older and
was reduced by 7.8% in patients receiving male cases with pre-existing medical
vitamin C. In six trials, the length of ICU conditions and below-normal vitamin D
stay was reduced by 8.6% following oral levels are associated with higher odds of
administration of vitamin C in doses of 1–3 death 14 . A retrospective study in the
g/day. In three trials in which patients mainland of USA included a large number
needed mechanical ventilation for over 24 of cases demonstrated that Sunlight and
hours vitamin C shortened the duration of vitamin D, with latitude as an indicator,
mechanical ventilation by 18.2% 11. possibly associated with reduced risks for
A new Randomized clinical trial to test both COVID-19 cases and mortality15.
high-dose intravenous vitamin C (24g/ day The abundant and nature gift of Vitamin D
for 7 days) in patients with COVID-19 has is sun rays. Exposure to sun rays between
begun in Wuhan, China. They will assess 11 am to 3 pm is recommended to get
requirements for mechanical ventilation and Vitamin D. The food rich in Vitamin D are
vasopressor drugs, organ failure scores, ICU egg yolk, fish oils, milk and milk product.
length of stay and 28-day mortality 9. The Vitamin D fortified foods such as oil, wheat
best sources of Vitamin C are amla, guava, flour can be consumed.
orange, lemon, tomato, bell peppers, Vitamin B12: One of the cohort
cabbage, sprouted grams, kiwi, greens. study demonstrated the protective effects of
Vitamin E: Vitamin E, a fat-soluble combined vitamin D, Mg and vitamin
vitamin, is a potent antioxidant and has the B12 against clinical deterioration of
ability to modulate host immune functions. COVID-19 13
Vitamin E deficiency is known to impair Zinc: Zinc plays a key role in the immune
both humoral and cellular immunity. It has system. Severe zinc deficiency depresses
both anti viral and anti oxidant properties. immune function in the humans. The body
Vitamin E helps to protect Immune cells. It requires zinc to develop and activate T-
acts against respiratory infections. Vitamin lymphocytes, which is a part of the immune
E is present in nuts, cooking oils, flax seeds. system. According to the current estimates,
the risk of zinc deficiency is observed in
Galore International Journal of Health Sciences and Research (www.gijhsr.com) 33
Vol.5; Issue: 3; July-September 2020V. Bhavani. Fasten the nutrients!! flatten the pandemic!! - core contribution of medical nutrition therapy in
COVID-19
more than 1.5 billion people in the world compared with non-survivors recovering
16
.One of the Indian study showed that Zinc with time in survivors while remaining low
intakes were below 50% of the RDA level or even declining in non-survivors 20. In
17
. Zinc status is also tightly associated with addition, selenium reduces the formation of
risk factors for severe COVID-19 including thrombosis in the blood vessels. According
ageing, immune deficiency, obesity, to Fogarty , blood coagulation disorders
diabetes, and atherosclerosis, since these are leading to the formation of micro-clots are a
known risk groups for zinc deficiency. significant cause of death in patients with
Therefore, Zinc may possess protective COVID-19 21 . The best sources of selenium
effect as preventive and adjuvant therapy of from food are Brazil nuts, seafoods, garlic,
COVID-19 through reducing inflammation, oats, seeds, liver, meat and whole grains.
improvement of mucociliary clearance, Iron : Iron is an essential mineral which
prevention of ventilator-induced lung injury, plays a key role in the making of healthy red
modulation of antiviral and antibacterial blood corpuscles. Iron deficiency anemia is
immunity. The combination of zinc and not only common in developing countries,
pyrithione at low concentrations inhibits the but it can also be seen in developed
replication of SARS coronavirus countries. It is the most common
(SARS‐CoV). Therefore, zinc supplement micronutrient deficiency worldwide. It
may have effect not only on exceeds 50% in developing countries and is
COVID‐19‐related symptom like diarrhea usually attributed to inadequate nutrition.
and lower respiratory tract infection, but Unfortunately, the majority of the female
also on COVID‐19 itself 4 . Zinc is loaded in population had intakes below the RDA for
almonds, walnuts, chick pea, lentils, iron in India. Its deficiency affects the
pumpkin seeds, flax seeds, gingelly seeds, capacity to have an adequate immune
eggs, shell fish and whole grains. response. The role of iron in immunity is
Selenium: Selenium contains antiviral and necessary for immune cell proliferation22.
anti oxidant property. Selenium prevents Some authors indicate that a mild/moderate
cell damage. Selenium is used in viral iron deficiency may have a protective effect
diseases like HIV and Covid 19. The lower on respiratory infections23. It is also
the Selenium status in a population, the indicated a 2-5.7 fold increase in the
lower the recovery rate from COVID-19. In incidence of acute lower respiratory tract
the city of Enshi, which has one the highest infections in patients with iron deficiency
Selenium intakes in the world, the recovery anemia24 . Iron deficiency has been reported
rate from COVID-19 was almost triple the as a risk factor for the development of
average for the rest of the cities in Hubei recurrent acute respiratory tract infections 4 .
Province, including Wuhan. Selenium status Thus to enhance the immunity among the
may offer a protective benefit against the population, it is necessary to consume Iron
detrimental effects of the viral infection18. rich foods and store the iron which acts
Selenium deficiency was more against the respiratory infections. The iron
severe in the samples obtained from non- sources in the food are Greens especially
survivors as compared with survivors of cauliflower leaves contains 40mg/ 100gm
COVID-19 may suggest some relevance of can be consumed regularly along with lime
the trace element for coping with the virus juice to correct iron deficiency. Dry
and for successful convalescence19. sundaikai, bajra, roasted bengal gram, liver,
Selenium Deficiency is Associated with rice flakes, mint, soya, lotus stem are
Mortality Risk from COVID-19. A sources of iron.
European cross sectional study conducted Omega: Omega‐3 and Omega‐6 PUFAs
among 1915 samples revealed that the predominantly promote anti‐inflammatory
Selenium status was significantly higher in and pro‐inflammatory effects4 .The impact
samples from surviving COVID patients as of dietary polyunsaturated fatty acids
Galore International Journal of Health Sciences and Research (www.gijhsr.com) 34
Vol.5; Issue: 3; July-September 2020V. Bhavani. Fasten the nutrients!! flatten the pandemic!! - core contribution of medical nutrition therapy in
COVID-19
(PUFAs) on the immune system has been sardines, arctic char and trout., eggs
investigated for decades, with special focus (including omega-3 enriched) ,
on the omega-3 PUFAs α-linolenic acid flaxseeds and flaxseed oil, walnuts,
(ALA), eicosapentaenoic acid (EPA), and soybeans, tofu, canola oil, chia seeds.
docosahexaenoic acid (DHA). ALA is found
in nuts and seeds whereas EPA and DHA IMMUNE BOOSTING FOODS
are the main components of fish oil. Both Traditional foods have been proven to be
omega-3 and omega-6-derived metabolites essential in human life by improving the
have important immune-regulatory immunity in daily basis not only for flavor
functions25. EPA and DHA supplementation and taste; but also for medicinal properties
can alter many biological pathways which as they contain various health promoting
may have direct influence in the outcome of compounds. Traditional foods help to boost
COVID-1926. The food sources are fatty the immunity. The below mentioned foods
fish like salmon, mackerel, anchovies, can be consumed regularly
Food Compound Dosage recommended
Black pepper Phenolic amides, flavonoids No specific dose
Ginger Gingerol 0.25 to 1g, 3 to 4 times a day
Turmeric Curcumin 400 to 600 mg, 1 to 3 times a day
Star Anise Anethol, fennel A pinch
Fresh Garlic Allicin 2 to 5 grams
Kolanji seeds Thymoquinone 2 grams
Fenugreek Saponins, flavonoids 5 grams
Coconut oil Lauric acid Only 4 teaspoon of any oil is recommended per day
Lemon Limonene No specific dosage
Sweet potato Carotene and Anthocyanin No specific dosage
Drumstick leaves Beta carotene No specific dosage
Immune boosting Drink: prepared by the additional burden to the health condition
boiling turmeric, ginger, pepper, lemon, and intervention programs. The Centers of
star anise, lemon, mint in water can be Disease Control (CDC) recommends at least
consumed daily to boost the immunity. thirty minutes of moderate physical activity
Milk with pepper and turmeric can be or brisk walking at least for five days in a
consumed daily. week for adults (one hundred and fifty
minutes of moderate-intensity physical
PHYSICAL ACTIVITY activity per week). Author suggests various
Physical activity can be defined as physical activities in this pandemic: yoga,
“any bodily movement produced by skeletal gardening, aerobics can be performed daily.
muscles that require expenditure”. Physical Walking in the terrace garden or jogging
inactivity or being sedentary is a fourth within the campus is recommended.
leading risk factor for global mortality and Meditation can be performed as a mode of
is a major contributing factor for various relaxation. This helps to enhance the
non-communicable diseases such as physical and mental health.
diabetes mellitus, cancer and heart
diseases27 (Roshini Rajappan, 2015). WHO CONCLUSION
reported that around 60% of the global Nutrition is a science required for a
population does not regularly meet the healthy life. World is facing a pandemic
recommended daily minimum physical situation, where food and nutrition plays a
activity. vital role in boosting the immunity of the
In the current Pandemic, since most population and also helps in the
of them are at home and quarantined, there intervention. As per the guidelines of WHO
is more chance of physical inactivity which and Nutritional societies, it is advised to
at the end leads to obesity and other non- avoid processed foods, foods with chemical
communicable Diseases. This may add on preservatives and excess salt. Consumption
Galore International Journal of Health Sciences and Research (www.gijhsr.com) 35
Vol.5; Issue: 3; July-September 2020V. Bhavani. Fasten the nutrients!! flatten the pandemic!! - core contribution of medical nutrition therapy in
COVID-19
of coloured vegetables and fruits (atleast 6. Belafsk PC., Mouadeb, DA et al., Validity
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