A Review of Recent Research
Dr. Paul Anderson 08-05-2020
I always find the “official” response to health crises interesting and even comical at times. COVID-19 (the acronym I will use here to indicate the disease caused by SARS-CoV-2 infection) has been the usual batch of interesting information and so much more. Even today (but especially in March and April) we were told by Government sources and the medical experts on each news outlet (and even some politicians) things such as: “nutrition does nothing to alter this disease”, “Vitamin D (or you fill in the nutrient) will not help”, “all these things are bunk” and on it goes. Add to this professional health care organizations warning their clinician members not to treat COVID- 19, not to post anything about it, not to (you fill in the prohibition) and it was an almost surreal experience watching things unfold. Before I summarize the peer reviewed data around COVID-19 and nutrients / nutrition I want to provide a few statements which I believe are foundational to having honest scientific discussion. First science is never “settled”, by its nature science is always learning, changing, and moving forward. So, having real firm ideas about the “science” around a new and emerging infection is dangerous. As I say in the podcasts it isn’t wise to predict the final score of a ballgame in the first few minutes of that game. Second, there is nothing mentioned here that is a “cure” or a “guarantee” of anything. You can have perfect health with no comorbidities and still get an infection and even die from it. That’s just the way infectious diseases work. Sure, you are less likely to get the infection (or a bad version of it) if healthy but the probability is not “zero”. In that same area is the fact that nothing I say here is a guarantee you won’t have post-COVID symptoms if all is right with your nutrient intake, again no guarantees. But what emerges is the fact that even with infection people do better the healthier they and their nutrient intake is.
All that said, common sense and logic seem to indicate that the better the human body is operating and the more components and determinants of health they have on their side the less likely an infection will arise or the more likely they will survive if they develop an infection. I would say this (with the noted caveats above) fits my experience in COVID-19 patients I have consulted with or on behalf of. If nutrition and nutrient status is so important, and I am citing eleven recent scientific publications about it, what is the current state of nutrient assessment and COVID-19? An author in a well-known critical care publication summarized the issue as follows: “Relatively little attention, however, is paid to the micronutrient status of COVID-19 patients. Micronutrients are vitamins and specific minerals that are critical to the proper structure and functioning of numerous proteins, enzymes, physiological processes, and signaling pathways within the body. Without these micronutrients, these essential processes cease to function properly, and this contributes to morbidity and, in cases of severe deficiency, mortality.” [1] “Therefore, it is important to consider that differences in susceptibility to, and severity of, COVID-19 could be partly due to insufficient micronutrient levels for adequate immune and organ function. As such, it would be of benefit to COVID-19 patients if critical care physicians take this into consideration and test for potential micronutrient insufficiencies in their patients and, if indicated, supplement with adequate amounts to restore normal status and function. This may help improve patient outcomes.” [1] I have been asked “is this nutrient level and disease connection new?” when people look at new publications in this area. The answer is no. Yes, this is an ever-evolving area of science and we will perpetually have new information, but it is certainly not “new science”. The authors of another recent paper summarize this clearly: “Immune support by micronutrients is historically based on vitamin C
deficiency and supplementation in scurvy in early times. It has since been established that the complex, integrated immune system needs multiple specific micronutrients, including vitamins A, D, C, E, B6, and B12, folate, zinc, iron, copper, and selenium, which play vital, often synergistic roles at every stage of the immune response.” [2] Food, nutrients, and quarantine… a common question I hear is if the activity of “sheltering in place” or quarantine etc. creates any particular nutritional issues. These authors wrote an excellent paper summarizing this: “Keeping foods that are good sources of immuno-supportive nutrients, planning times to eat, meals, portions and having a cutoff time for eating but mostly having in mind positive attitudes could be helpful to tackle the negative health effects of quarantine.” [3] Of course their work is in much more depth but this gives you the idea. A paper with an excellent “deep dive” into individual nutrients (so if you would like that information please look that paper (reference 4 below) up on any search engine) concludes: “Our primary conclusion is that it is vitally important to maintain a healthy diet and lifestyle during the pandemic.
This is especially important for the vulnerable in our society. In particular, those at high risks of infection should at least maintain their nutritional status by ensuring they reach their RDA of the potentially beneficial nutrients outlined in this review.” [4] A paper with some excellent bulleted lists with guidance toward better diet choices underscores the scientific basis and connection of diet to immunity: “A balanced diet will guarantee a strong immune system that can help withstand any assault by the virus.” [5] Other authors are even more explicit in their conclusions: “For a viral disease like COVID-19, where no pharmacological strategies for prevention or treatment are presently available and where the exact time of the ending of the alarming situation is unknown, nutritional strategies for enhancing immunity is something to be explored. In addition to treating malnutrition and weight reduction in obese healthy subjects, in this review, we have highlighted the potential preventive and therapeutic application of a few vitamins, trace elements, several nutraceuticals, and probiotics.” [6] Another group of authors publishing in the British Medical Journal also looked deeply at the research on nutrient and probiotic supplementation (if you like lists of good data in one place, this [7] is your paper) in potentially moderating some of the more deadly facets of severe COVID-19 infection. “Severe infection of the respiratory epithelium can lead to ARDS, characterized by excessive and damaging host inflammation, termed a cytokine storm. This is seen in cases of severe COVID-19. There is evidence from ARDS in other settings that the cytokine storm can be controlled by the n-3 fatty acids EPA and DHA,
possibly through their metabolism to SPMs. This therapeutic approach has not been attempted in severe COVID-19 and warrants investigation.” [7] Another group of authors echo the idea that nutrients can even affect the most severe parts of COVID-19 disease “There has been a gradual increase in studies exploring prevention and control measures, and we recommend paying close attention to nutrition, which may contribute to modulating some important consequences of COVID-19 infection, as such pro-inflammatory cytokine storm.” [8] This paper also has some excellent graphics if you are a visual learner! I find it also encouraging that papers are even addressing not only personal nutrition but also local, national, and global policies. [9] Additionally, papers are emerging addressing the need for better nutrition and nutritional support in hospitalized patients. [11]
So, what do we do?
Keeping in mind that I am a doctor, but I am not ‘your’ doctor… please take all this as scientifically derived ideas to discuss with your healthcare provider. This is data, not medical advice.
Sleep: Less sleep equals less immune function. Hydration: For many reasons hydration helps immunity and overall health. It especially helps the preventive defenses in the respiratory system where most COVID-19 enters. Movement: Muscle activity = healthy metabolism / Fat activity = less healthy metabolism. Thick or thin, sedentary or active just do something through the day to keep your muscles in motion. Mind: You are what you think. Really. The epigenetics that control your world (and your immune system) are highly influenced by messages. Those influences are not only what you tell yourself but also what messages you are listening to, who you stay around and other external factors. You: There are MANY other ‘lifestyle’ things to consider but generally anything that brings you joy and empowerment is important to your immunity. Diet: The references below have great ideas. Clean eating is critical (low toxin food from non-processed sources, organic where you can etc.) to overall nutrient intake and health. Many ideas on this are found in the papers below and in my podcast library (“Medicine and Health with Dr. Paul Anderson). Supplemental Nutrients: While this list is endless the data I summarized here points to a core group you can start with. There are many that may be more or less indicated for your personal situation which again underscores the idea that these suggestions need competent guidance from a health care provider trained in nutritional medicine. I personally take all these with food to speed digestion of the supplement and decrease stomach upset.
NOTE: “Initially” and “Short term” indicate induction therapy to raise your levels. This can be as short as a month or as long as three months or the duration of the disease. Again obtain guidance about this from your healthcare provider.
Vitamin A in its fat-soluble form. Initially I use 25,000 to 50,000 IU per day then taper that down to 12,500 IU for maintenance. Medical conditions such as liver and other organ issues as well as pregnancy need careful monitoring if therapeutic doses of Vitamin A are used. Vitamin C. Most people get diarrhea with too much Vitamin C so “bowel tolerance” is a good measurement of sufficiency. I start at 500 to 1,000 mg each meal and increase to bowel tolerance. Humans do not make their own Vitamin C and it is water soluble (unlike Vitamin A) so tolerance can be quite high during infections.
Vitamin D. Fat-soluble like Vitamin A so you can get too much, but in infections short term it is normally helpful. If you have your levels checked and they are normal then whatever you take for maintenance is likely fine. If you do not know then 25,000 – 50,000 IU for a short time can be useful. If your Vitamin D supplement has Vitamin K2 (another fat-soluble vitamin) then that is great. Adding Vitamin K2 to Vitamin D is more critical long term.
The B-vitamins. A group of vitamins found in many foods the B-vitamins are critical to many functions in the body. They are water soluble like Vitamin C so you use many up each day. A good multi-vitamin or a “B-Complex” supplement can help as a source. Minerals are critical and most work with vitamins in biochemical reactions in the body. While zinc has become the “famous mineral” around COVID-19 many other minerals assist immune function. I mostly have people get a multi-mineral for short term use which has many trace minerals including zinc,
selenium, chromium and many others. If higher levels of zinc are taken long term copper is required to balance it (short term this is not an issue). If one is wanting to optimize zinc for immune purposes short term 30 to 50 milligrams twice a day with food is a common recommendation. Most multi-mineral supplements already have 20 to 50 milligrams of zinc so if you were going for more zinc keep that in mind. As I have said before make sure you take minerals (especially zinc) half way through a meal and drink water with it so you do not have nausea.
N-acetyl-cysteine (NAC). An amino acid this substance supports glutathione formation which is critical and helps keep the protective mucus in the respiratory tract healthy. I usually have people take 500 milligrams each meal for the short term.
Quercetin (a bioflavinoid). Quercetin is an infamous “zinc ionophore” which theoretically helps zinc slow viral replication. I take 500 milligrams twice a day with meals. As mentioned in the papers above probiotics and omega-3 oils can be quite helpful. These generally need some specific guidance for your particular state of health. And yes there are many others. But if you get most of the above in your diet and then supplement on top (of your diet) you likely have a higher level of protection and immune support.
References cited:
1. Carr AC. Micronutrient status of COVID-19 patients: a critical consideration. Crit Care. 2020;24(1):349. Published 2020 Jun 16. doi:10.1186/s13054-020-03085-0
2. Gombart AF, Pierre A, Maggini S. A Review of Micronutrients and the Immune System-Working in Harmony to Reduce the Risk of Infection. Nutrients. 2020;12(1):236. Published 2020 Jan 16. doi:10.3390/nu12010236
3. Muscogiuri G, Barrea L, Savastano S, Colao A. Nutritional recommendations for CoVID-19 quarantine. Eur J Clin Nutr. 2020;74(6):850-851. doi:10.1038/s41430-020-0635-2
4. Zabetakis I, Lordan R, Norton C, Tsoupras A. COVID-19: The Inflammation Link and the Role of Nutrition in Potential Mitigation. Nutrients. 2020;12(5):1466. Published 2020 May 19. doi:10.3390/nu12051466
5. Aman F, Masood S. How Nutrition can help to fight against COVID-19 Pandemic. Pak J Med Sci. 2020;36(COVID19-S4):S121-S123. doi:10.12669/pjms.36.COVID19-S4.2776
6. Jayawardena R, Sooriyaarachchi P, Chourdakis M, Jeewandara C, Ranasinghe P. Enhancing immunity in viral infections, with special emphasis on COVID-19: A review. Diabetes Metab Syndr. 2020;14(4):367- 382. doi:10.1016/j.dsx.2020.04.015
7. Calder PC. Nutrition, immunity and COVID-19. BMJ Nutrition, Prevention & Health. 2020;bmjnph- 2020-000085. doi:10.1136/bmjnph-2020-000085
8. Cena H, Chieppa M. Coronavirus Disease (COVID-19-SARS-CoV-2) and Nutrition: Is Infection in Italy Suggesting a Connection?. Front Immunol. 2020;11:944. Published 2020 May 7. doi:10.3389/fimmu.2020.00944
9. Naja F, Hamadeh R. Nutrition amid the COVID-19 pandemic: a multi-level framework for action [published online ahead of print, 2020 Apr 20]. Eur J Clin Nutr. 2020;1-5. doi:10.1038/s41430-020-0634-3
10. Butler MJ, Barrientos RM. The impact of nutrition on COVID-19 susceptibility and long-term consequences. Brain Behav Immun. 2020;87:53-54. doi:10.1016/j.bbi.2020.04.040
11. Laviano A, Koverech A, Zanetti M. Nutrition support in the time of SARS-CoV-2 (COVID-19). Nutrition.
2020;74:110834. doi:10.1016/j.nut.2020.110834
