Targeted nutrition support in the battle against COVID-19
Dicken Weatherby, N.D. and Beth Ellen DiLuglio, MS, RDN, LDN
Identifying nutrition risk early in the course of COVID-19 is crucial to optimizing treatment.
The ODX COVID-19 Series
- COVID-19: The pandemic that has become endemic
- COVID-19: Overlapping risk factors and chronic disease
- Nutritional status and COVID-19: A covert factor in disease susceptibility
- COVID-19: Blood chemistry biomarker patterns - Clues and patterns lurking just under the surface
- COVID-19: Blood chemistry biomarker patterns - Down the research rabbit hole
- COVID-19: Blood Biomarkers - Neutrophils
- COVID-19: Blood Biomarkers - Albumin
- COVID-19: BloodBiomarkers - Cytokines
- COVID-19: Blood Biomarkers - Interleukin-6
- COVID-19: Blood Biomarkers - Interleukin-10
- COVID-19: Blood Biomarkers - Vitamin C
- COVID-19: Blood Biomarkers - Vitamin D
- COVID-19: Blood Biomarkers - Zinc
- Biomarker characteristics and blood type - help sharpen the COVID-19 clinical picture
- COVID-19: Initial indications and conventional interventions
- COVID-19: Long-term risk reduction - Naturopathic, functional medicine, and nutrition-based approaches to prevention
- A healthy diet is primary prevention for COVID-19
- You should have a gut feeling about COVID-19
- Beyond dietary food patterns…plant-based compounds may mitigate COVID-19 risk
- Targeted nutrition support in the battle against COVID-19
- Targeted nutrition support in COVID-19: Armed with vitamin C
- Targeted nutrition support in COVID-19: In sync with zinc
- Targeted nutrition support in COVID-19: Micronutrients and phytonutrients are important players
- Optimal Takeaways for improving immunity and reducing susceptibility to COVID-19
- Optimal - The Podcast: Episode 8 -Blood Biomarkers and Risk Factors for COVID-19 and its Comorbidities
Nutrition screening, assessment, and intervention should be part of an initial evaluation of COVID-19.
In April of 2020, Italian researchers shared protocols designed to identify, address, and mitigate compromised nutrition status in COVID-19 patients. [i] Key points include:
- Intake history, weight for height, and body composition assessment (may be difficult to obtain in the acute setting)
- Increased nutrition risk is associated with a BMI of less than 22, weight loss in the past 3 months, or history of or anticipated reduction in food intake.
- Note that obesity, especially a BMI of greater than 30 is associated with severe COVID-19 as well and can be associated with protein and micronutrient insufficiencies.
- If tolerated, oral nutrition support with calorie and protein-dense foods and supplements should be implemented as early as possible.
- 2-3 bottles of oral nutrition supplements provided daily should provide an additional 600-900 Calories and 35-55 grams of protein per day.
- If less than 2 bottles are consumed, then parenteral nutrition support may be indicated.
- Whey protein (20 grams/day) supplementation is especially important due to its immunomodulatory properties and antiviral potential.
- If oral intake is inadequate, intravenous supplementation with amino acids, vitamins, minerals, and trace elements should be initiated. Essential fatty acids may need to be administered periodically.
- Nasogastric enteral nutrition support may be contraindicated in those on non-invasive ventilation or CPAP therapy.
- Total energy and protein needs can help guide nutrition support.
- Energy needs are calculated using the Harris-Benedict factor for basal metabolic rate multiplied by a factor of 1.5. Estimates of 25-30 kcals/day may suffice as well.
- Calculated protein needs of 1.5 grams of protein per kilogram of actual body weight should provide adequate amino acids for increased metabolic needs.
- Estimated needs for obese patients with a BMI greater than 30 are based on ideal body weight instead of actual body weight.
- Low albumin and elevated C-reactive protein are independent prognostic markers for progression to pneumonia.
- Low prealbumin levels were also useful in predicting respiratory failure and need for mechanical ventilation.
- Address vitamin D status due to its ability to reduce inflammation, improve immunity against pathogens, and enhance recovery during antiviral therapy. Appropriate supplementation should be provided:
- For serum 25(OH)D below 20 ng/mL [50 nmol/L], provide 50,000 IU vitamin D3 per week
- For serum 25(OH)D 20-29 ng/mL [50-72 nmol/L], provide 25,000 IU vitamin D3 per week.
In general, critically ill COVID-19 patients benefit from balanced nutrition support:[ii]
- Total Calories 20-30 kcal/kg, adjust for tolerance, morbidity, refeeding if underweight
- Protein 3-1.5 grams/kg, up to 50% branched chain amino acids
- Carbohydrate Up to 70% with no respiratory deficiency, 50% on ventilator
Or 2 grams carbohydrate /kg body weight up to 150 grams/day
- Fat 5 grams/kg body weight, incorporate medium and long-chain fatty acids
Note that supplementation with omega-3 fatty acids during viral infection and treatment is controversial and must be considered on a case-by-case basis.[iii] [iv] [v]
Advanced age and comorbidities are associated with impaired nutritional status and muscle wasting/sarcopenia (despite higher BMI), further linking COVID-19 risk factors to nutritional status. While low albumin in COVID-19 patients may reflect inflammation versus pre-existing malnutrition, reductions in prealbumin levels may be predictive of progression to ARDS.[vi]
Increased levels of CRP reflect inflammation, an oxidative process that can deplete antioxidants in the body. Analysis of NHANES III data found that levels of CRP were significantly inversely associated with antioxidants vitamin C, alpha and beta-carotene, retinol, retinyl esters, cryptoxanthin, lycopene, lutein/zeaxanthin, and selenium. Since severe COVID-19 is associated with significant inflammation, therapeutic antioxidant intervention should be considered.[vii]
[i] Caccialanza, Riccardo et al. “Early nutritional supplementation in non-critically ill patients hospitalized for the 2019 novel coronavirus disease (COVID-19): Rationale and feasibility of a shared pragmatic protocol.” Nutrition (Burbank, Los Angeles County, Calif.) vol. 74 (2020): 110835. doi:10.1016/j.nut.2020.110835 [R]
[ii] Fernández-Quintela, Alfredo et al. “Key Aspects in Nutritional Management of COVID-19 Patients.” Journal of clinical medicine vol. 9,8 2589. 10 Aug. 2020, doi:10.3390/jcm9082589 [R]
[iii] Gutiérrez S, Svahn SL, Johansson ME. Effects of Omega-3 Fatty Acids on Immune Cells. Int J Mol Sci. 2019 Oct 11;20(20). pii: E5028. doi: 10.3390/ijms20205028. Review. PubMed PMID: 31614433; PubMed Central PMCID: PMC6834330. [R]
[iv] Caccialanza, Riccardo et al. “Early nutritional supplementation in non-critically ill patients hospitalized for the 2019 novel coronavirus disease (COVID-19): Rationale and feasibility of a shared pragmatic protocol.” Nutrition (Burbank, Los Angeles County, Calif.) vol. 74 (2020): 110835. doi:10.1016/j.nut.2020.110835 [R]
[v] Kolawole, E. M., & Evavold, B. D. (2016). Omega-3 rich diet alters T cell affinity and decreases anti-viral immunity. [R]
[vi] Laviano, Alessandro et al. “Nutrition support in the time of SARS-CoV-2 (COVID-19).” Nutrition (Burbank, Los Angeles County, Calif.) vol. 74 (2020): 110834. doi:10.1016/j.nut.2020.110834 [R]
[vii] Ford, E S et al. “C-reactive protein concentration and concentrations of blood vitamins, carotenoids, and selenium among United States adults.” European journal of clinical nutrition vol. 57,9 (2003): 1157-63. doi:10.1038/sj.ejcn.1601667 [R]