key: cord-291340-8gj0ofmp
authors: Misra, Anoop
title: Balanced Nutrition is Needed in Times of COVID19 Epidemic in India: A Call for Action for all Nutritionists and Physicians
date: 2020-08-27
journal: Diabetes Metab Syndr
DOI: 10.1016/j.dsx.2020.08.030
sha: 
doc_id: 291340
cord_uid: 8gj0ofmp

nan

Diet in patients not infected with COVID19 infection, having mild COVID19 as well as those who have recovered from COVID19 infection should be balanced. It is reasonable to suggest that all individuals should continue to follow principles of healthy diets, and specific recommendations about consumption of sugar, salt, refined carbohydrates, edible oil, saturated fats and trans fatty acids, total dietary fibre, processed and canned foods [15] [16] [17] . Particularly diets which require major changes in macro-and micronutrients and fasting (e.g. ketogenic diets, intermittent fasting) must be avoided during this time. There is some research which supports that specific foods and dietary nutrients may decrease risk of viral infections. In this context proteins, vitamins, minerals, trace elements, prebiotics, probiotics, omega-3 polyunsaturated fatty acids and specific diets have been researched, but direct research on COVID19 patients are lacking. In the following paragraph we summarise the role of some specific nutrients vis-a-vis immunity.

Intake of certain nutrients may be the reason behind variations to susceptibility of individuals or populations to COVID19. In this respect, the effect of some nutrients on angiotensin-converting enzyme (ACE2) receptor, which facilitates entry of SARS-Coronavirus-2 to human cells, needs further discussion. Theoretically, any inhibition of ACE enzyme would lead to changed metabolic pathways which has potential for lung protection. Broccoli protein hydrolysate has shown to have angiotensin-converting enzyme (ACE) inhibitory activity in vitro and hypotensive effect in vivo [18] . Some dairy products, eggs etc. may also have capacity for ACE inhibition [19] , while saturated fat increases ACE levels [20] . Cabbage contains precursors of sulforaphane, which is an active natural activator of nuclear factor (erythroid-derived 2)-like 2 (Nrf2), which influences angiotensin II receptor type 1 axis. Fermented vegetables contain many lactobacilli, which are also potent Nrf2 activators [21] . These authors point out that populations in Eastern Asia, Central Europe or the Balkans eat large quantities of fermented foods, which has implications to COVID19 related mortality [21] . Clinical benefits of these foods in context of COVID19 are yet to be proved.

There is no doubt that protein deficiency must be avoided. Protein undernutrition can cause anaemia, vascular dysfunction, and impaired immunity. Protein intake must be adequate even in healthy elderly since low albumin levels predict increased mortality [22] . Research on micronutrients and minerals regarding immunity is a continuing area of interest. Vitamin C has been shown to be severely depleted in critically ill patients at admission, and more so in patients with sepsis. In such patients mega doses are required in grams [23] . Importantly, pneumonia and other respiratory infections are commonly seen in severe vitamin C deficiency [24] . There is some evidence that Vitamin C may reduce infections, vascular injury and inflammation in acute respiratory distress syndrome [24, 25] . It is possible, but not proven, that vitamin C status is severely low in COVID19 associated pneumonia, however, more research is needed. Probiotics have been shown to decrease growth of pathogenic bacteria, decrease inflammation and enhance immunity. In a Cochrane review [26] , and other studies [27] probiotics were shown to decrease upper respiratory infections through their effect on the gut lung axis [28] Role of several other nutrients and food constituents like Vitamins(E, B) Carotenoids, minerals (Fe, Zn, Mg, Cu, Se), and polyphenols in immunity have been suggested because of their effects on inflammatory cascade, antioxidant activities and effects on nitrous oxide signalling pathways [25] (Table 1) . Recent data on status of vitamins B1, B6, B12, D (25-hydroxyvitamin D), folate, selenium, and zinc levels are available in 50 hospitalized Korean patients with COVID-19. Among these, 76% patients were vitamin D and 42% were selenium deficient, while other vitamin and mineral deficiencies were not present [29] .

In an comprehensive review of 662 studies, Jayawardena et al [30] concluded that vitamins, A and D showed a potential benefit in viral diseases, particularly in people who are deficient. Vitamin D has a role in immunomodulation, and its deficiency has been shown to be correlated to mortality in COVID19 [31] , however, there are currently no intervention trials. Among trace elements, selenium and zinc have also shown favourable immunomodulatory effects in viral respiratory infections [30] .Regarding the former, sodium selenite, a most common water soluble selenium compound, can oxidize thiol groups in the virus protein disulfide isomerase resulting in its inability to penetrate the healthy cell membrane [32] . In this context, it is important to note that selenium deficiency was found to be associated with mortality in patients with COVID19 [33] . Zinc deficiency is common worldwide, and such individuals have an increased risk of acquiring viral infections such as HIV or hepatitis C virus [34] . In Vero-E6 cells, zinc inhibited SARS-coronavirus RdRp template binding and elongation [35] . However, its role in adult pneumonias or COVID19 has not been proven. Fish oils have some role in boosting immune functions, and decreasing inflammation and thrombotic events [36, 37] Interestingly infusion of omega-3 fatty acid lipid emulsion in critically sick patients with sepsis was associated with improved survival [38] but research on patients with COVID19 is lacking. A few researchers have suggested that coronaviruses use purine nucleotides which could promote RNA synthesis [39] , hence low purine diets may be beneficial [27] . Interestingly, curcumin has been shown to bind to target on the SARS-CoV-2 receptor [40] .

When individuals have severe COVID19 infections, marked nutritional deficiencies may rapidly occur due to increased energy expenditure (fever, mechanical ventilation), decreased intake (loss of appetite, nausea, vomiting, diarrhoea), accelerated metabolism and reduced synthesis of nutrients (e.g. proteins). It is important that such malnutrition is recognised quickly (one can resort to screening scores for malnutrition risk), particularly in vulnerable populations (e.g. elderly, those with multiple co-morbidities, cancer etc.) and given adequate importance and treated [36] . This could be achieved by oral nutritional supplements, enteral feeding with nasogastric tube, and parenteral nutrition (Table 1) [15, 16, 30, 36, 41, 42] . Medical nutrition therapy should be instituted as soon as possible after intensive care unit (ICU)admission [42] . It is important that feeding formulas contain balance of macro-and micronutrients. Details of intake of energy, protein and other nutrients are beyond purview of this article and other reviews should be referred [36] } [41, 42] . In hospitalised patients, maintaining good protein intake is important to avoid hypoalbuminemia. Specifically, albumin levels may decrease rapidly due to preexisting poor nutritional status; inflammation, decreased production by liver, and acute severe catabolic state. Several studies show that low albumin levels in hospitalised patients lead to increased mortality [43] [44] [45] , morbidity, increased ICU stay and increased resource utilisation [44] . Acute kidney injury, a known complication in patients with COVID19, when complicated with hypoalbuminemia, may further increase mortality as shown in a meta-analysis [46] . Controlled trials also show reduced complications when serum albumin level is adequate [44] .In a recent scoping review(four studies in patients with ventilator-related pneumonia and acute respiratory distress syndrome, and the other 4 in patients with ventilator-associated pneumonia), intravenous ascorbic acid, intramuscular cholecalciferol, enteral and intramuscular vitamin E, enteral zinc sulphate, and oral and parenteral glutamine were given as interventions. Most (6/8) studies did not have baseline status of the nutrient of interest. The authors state it was not possible to evaluate efficacy of such interventions because of inadequate baseline data [47] .

In the absence of clear and robust evidence showing efficacy of specific nutrients and minerals, it is best practice to rely on traditional dietary advice with enhanced servings of proteins, local and seasonal fruits and vegetables, overall rounding off to have a balanced diet. [47] (Table 1) . We believe that the J o u r n a l P r e -p r o o f above knowledge and discussion on nutrition in COVID19 will enable physicians and physicians to disseminate this knowledge. Finally, a call for action by the nutritionist and physician community to proactively discuss and implement healthy dietary practices and appropriate nutrition in all individuals and admitted patients with COVDID19 is crucial at this time.

Corresponding author: Anoop Misra National Diabetes, Obesity and Cholesterol Foundation (N-DOC), and Fortis CDOC Hospital for Diabetes, Metabolic Diseases and Endocrinology New Delhi, India. 

Recommended:

• Fruits, vegetables, legumes (e.g. lentils, beans), nuts and whole grains e.g. unprocessed maize, millet, oats, wheat, brown rice or starchy tubers or roots such as potato, and foods from animal sources (e.g. fish, eggs, milk meat,). o Daily:2 cups of fruit (4 servings), 2.5 cups of vegetables (5 servings), 180 g of grains, and 160 g of non-vegetarian foods (fish, lean meats, and poultry) • Snacks: choose raw vegetables and fresh fruits rather than foods that are high in sugar, fats, or salt. 

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