(Read a summary of this guide.)
You are strong! You made it home. But your fight is not yet over. In order to return to health, it is important to restore muscle and strength as well as provide your body with the nutrients it needs to keep your immune system strong.
Combining physical rehabilitation with nutrition rehabilitation is the way to go to improve your quality of life.
While hospitalized, your body used all the energy it had to fight the virus. This fight, coupled with bedrest, resulted in loss of valuable muscle. It is imperative to rebuild now, and this rebuilding process can take a long time. It requires on-going vigilance and can take more than a year. You can do this!
Below please find an outline of nutritional action steps you can take to rebuild your strength and return to activities of daily life. Keep your eye on the prize!
Creating and following a routine and schedule for meals and snacks will help to ensure you get in the calories and nutrients you need. If your appetite is suppressed this will really be essential. Even though eating was once a pleasure and may seem now to be a chore, it is imperative to your recovery. Initially, your taste sensation may be altered, and food may not be appealing. During this time, consider choosing foods with different textures (crunchy, creamy, etc.) to keep the sensation of eating somewhat engaging. If the smell of food is off-putting, choose foods you can eat cold (sandwiches, cold pasta salads or other grains, cottage cheese/Greek yogurt with fruit, etc.). Try different flavors if appealing or keep bland if preferred. Rest assured that will pass and your taste buds should awaken again. Until then, you still need to get in calories and pay particular attention to getting in adequate protein throughout the day.
If so, please access your local food bank:
Protein Supplements may help you reach your protein goals.
Adequate calories are necessary to reduce stress on your body and allow the food you consume to go toward re-building your strength. If you "under-eat", you stress your body’s systems. Your body will be in a catabolic, or break-down, state.
Table: Recommended daily calories by weight
Weight in LBS
Weight in Kg
There is much chatter on-line and, frankly, everywhere, about ‘boosting" your immune system. In fact, your immune system cannot be ‘boosted". It is working or it can be suppressed to different degrees (e.g. chemo, immune suppressing medications, or auto immune diseases). Do not fall prey to those who are selling unfounded compounds, elixirs, potions or isolated nutrients to help you "boost" your immunity. Recognize there are times when a vitamin or mineral will be suggested in a higher therapeutic dose, which is different than the amount you need to maintain a healthy immune system. Below, we offer some guidance on science based recommendations for nutrients and the amounts to help you maintain a healthy immune system.
Vitamin C is found in many fruits and vegetables. [See the chart below] If you do not like one, try another (look at the list and circle the ones you like and/or are willing to try!) Since Vitamin C is water soluble and is utilized so often in your body, it is ideal to consume a food with Vitamin C with each meal to ensure your body has the defense it needs throughout day. For example, an orange with breakfast, some sweet red pepper in a salad or on your sandwich at lunch, and some tomato sauce with dinner and/or mango for dessert.
The RDA (recommend daily allowance) for Vitamin C is 95 mg for men, 75 mg for women, and 35 mg more if a smoker or you exercise regularly.
Eating whole foods is preferred to supplements because:
Table: Amounts of vitamin C in select foods:
|Food||Milligrams (mg) per serving||Percent (%) DV*|
|Red pepper, sweet, raw, ½ cup||95||106|
|Orange juice, ¾ cup||93||103|
|Orange, 1 medium||70||78|
|Grapefruit juice, ¾ cup||70||78|
|Kiwifruit, 1 medium||64||71|
|Green pepper, sweet, raw, ½ cup||60||67|
|Broccoli, cooked, ½ cup||51||57|
|Strawberries, fresh, sliced, ½ cup||49||54|
|Brussels sprouts, cooked, ½ cup||48||53|
|Grapefruit, ½ medium||39||43|
|Broccoli, raw, ½ cup||39||43|
|Tomato juice, ¾ cup||33||37|
|Cantaloupe, ½ cup||29||32|
|Cabbage, cooked, ½ cup||28||31|
|Cauliflower, raw, ½ cup||26||29|
|Potato, baked, 1 medium||17||19|
|Tomato, raw, 1 medium||17||19|
|Spinach, cooked, ½ cup||9||10|
|Green peas, frozen, cooked, ½ cup||8||9|
Zinc is another mineral essential for a healthy immune system. If you are deficient in zinc, you are at higher risk for infection. However, if you have adequate zinc, more is not better. In fact, too much zinc can interfere with immune function, cause a copper deficiency, and decrease HDL (‘good") cholesterol as well as decrease the efficacy of certain medications, like antibiotics.
See list of food sources of zinc below. Circle the ones you like or are willing to try.
The RDA (recommended daily allowance) for Zinc is:
Table: Selected Food Sources of Zinc
|Food||Milligrams (mg) Per Serving|
|Oysters, cooked, breaded and fried, 3 ounces||74.0|
|Beef chuck roast, braised, 3 ounces||7.0|
|Crab, Alaska king, cooked, 3 ounces||6.5|
|Beef patty, broiled, 3 ounces||5.3|
|Lobster, cooked, 3 ounces||3.4|
|Pork chop, loin, cooked, 3 ounces||2.9|
|Baked beans, canned, plain or vegetarian, ½ cup||2.9|
|Breakfast cereal, fortified with 25% of the DV for zinc, 1 serving||2.8|
|Chicken, dark meat, cooked, 3 ounces||2.4|
|Pumpkin seeds, dried, 1 ounce||2.2|
|Yogurt, fruit, low fat, 8 ounces||1.7|
|Cashews, dry roasted, 1 ounce||1.6|
|Chickpeas, cooked, ½ cup||1.3|
|Cheese, Swiss, 1 ounce||1.2|
|Oatmeal, instant, plain, prepared with water, 1 packet||1.1|
|Milk, low-fat or non fat, 1 cup||1.0|
|Almonds, dry roasted, 1 ounce||0.9|
|Kidney beans, cooked, ½ cup||0.9|
|Chicken breast, roasted, skin removed, ½ breast||0.9|
|Cheese, cheddar or mozzarella, 1 ounce||0.9|
|Peas, green, frozen, cooked, ½ cup||0.5|
|Flounder or sole, cooked, 3 ounces||0.3|
Vitamin D has been found to be more than just a vitamin. It is actually a hormone in the body and is involved in many different systems from bone health to muscle function and even immunity.
Table: Selected Food Sources of Vitamin D
|Cod liver oil, 1 tablespoon||34.0||1,360|
|Trout (rainbow), farmed, cooked, 3 ounces||16.2||645|
|Salmon (sockeye), cooked, 3 ounces||14.2||570|
|Mushrooms, white, raw, sliced, exposed to UV light, 1/2 cup||9.2||366|
|Milk, 2% milkfat, vitamin D fortified, 1 cup||2.9||120|
|Sardines (Atlantic), canned in oil, drained, 2 sardines||1.2||46|
|Soy, almond, and oat milks, vitamin D fortified, various brands, 1 cup||2.5-3.6||100-144|
|Ready-to-eat cereal, fortified with 10% of the DV for vitamin D, 1 serving||2.0||80|
|Egg, 1 large, scrambled (vitamin D is in the yolk)||1.1||44|
|Liver, beef, braised, 3 ounces||1.0||42|
|Tuna fish (light), canned in water, drained, 3 ounces||1.0||40|
|Cheese, cheddar, 1 ounce||0.3||12|
|Mushrooms, portabella, raw, diced, 1/2 cup||0.1||4|
|Chicken breast, roasted, 3 ounces||0.1||4|
|Beef, ground, 90% lean, broiled, 3 ounces||0||1.7|
How do you know if you have enough Vitamin D?
Table: Serum 25-Hydroxyvitamin D [25(OH)D] Concentrations and Health*
|<30||<12||Associated with vitamin D deficiency, leading to rickets
in infants and children and osteomalacia in adults
|30 to <50||12 to <20||Generally considered inadequate for bone and overall health
in healthy individuals
|≥50||≥20||Generally considered adequate for bone and overall health
in healthy individuals
|>125||>50||Emerging evidence links potential adverse effects to such
high levels, particularly >150 nmol/L (>60 ng/mL)
Other than our skin, our gut is a first line defense against infection. It may be hard to believe, but our digestive tracts may, or may not, screen out ‘bad’ bacteria and infection from getting into our system. The health and make up of our gut are influenced by genetics, the food we eat, medications we take, and the environment we live in. As we get older, our bodies become less able to maintain a healthy environment in our gut.
Did you know that your muscles and bones talk to each other? And, as you lose muscle, you lose bone density. So, once again, continuing to build strength and doing the rehabilitative exercises, coupled with eating protein and calories, will help you in so many ways. Vitamin D, as stated above, is a crucial nutrient for bone health and necessary to absorb calcium from food!
Omega 3 fatty acids (Omega 3’s) may help with reducing excess inflammation. As you recover, your body may be experiencing a significant amount of inflammation as a result of fighting this infection, so consuming food based sources of omega 3’s could be helpful.
Table: Selected Food Sources of ALA, EPA, and DHA
|Food||Grams per serving|
|Flaxseed oil, 1 tbsp||7.26|
|Chia seeds, 1 ounce||5.06|
|English walnuts, 1 ounce||2.57|
|Flaxseed, whole, 1 tbsp||2.35|
|Salmon, Atlantic, farmed cooked, 3 ounces||1.24||0.59|
|Salmon, Atlantic, wild, cooked, 3 ounces||1.22||0.35|
|Herring, Atlantic, cooked, 3 ounces*||0.94||0.77|
|Canola oil, 1 tbsp||1.28|
|Sardines, canned in tomato sauce, drained, 3 ounces*||0.74||0.45|
|Mackerel, Atlantic, cooked, 3 ounces*||0.59||0.43|
|Salmon, pink, canned, drained, 3 ounces*||0.04||0.63||0.28|
|Soybean oil, 1 tbsp||0.92|
|Trout, rainbow, wild, cooked, 3 ounces||0.44||0.40|
|Black walnuts, 1 ounce||0.76|
|Mayonnaise, 1 tbsp||0.74|
|Oysters, eastern, wild, cooked, 3 ounces||0.14||0.23||0.30|
|Sea bass, cooked, 3 ounces*||0.47||0.18|
|Edamame, frozen, prepared, ½ cup||0.28|
|Shrimp, cooked, 3 ounces*||0.12||0.12|
|Refried beans, canned, vegetarian, ½ cup||0.21|
|Lobster, cooked, 3 ounces*||0.04||0.07||0.10|
|Tuna, light, canned in water, drained, 3 ounces*||0.17||0.02|
|Tilapia, cooked, 3 ounces*||0.04||0.11|
|Scallops, cooked, 3 ounces*||0.09||0.06|
|Cod, Pacific, cooked, 3 ounces*||0.10||0.04|
|Tuna, yellowfin, cooked 3 ounces*||0.09||0.01|
|Kidney beans, canned ½ cup||0.10|
|Baked beans, canned, vegetarian, ½ cup||0.07|
|Ground beef, 85% lean, cooked, 3 ounces**||0.04|
|Bread, whole wheat, 1 slice||0.04|
|Egg, cooked, 1 egg||0.03|
|Chicken, breast, roasted, 3 ounces||0.02||0.01|
|Milk, low-fat (1%), 1 cup||0.01|
Supplementation is primarily found in the form of EPA and DHA through fish, krill or algal oils. While research varies on ideal dosage, the USDA recommends not consuming more than 3 grams a day of EPA and DHA combined (max 2 grams from supplements; 1 g EPA + 1 g DHA) without being supervised by a physician as larger doses could cause bleeding problems (especially if you take an anti-coagulant) and possibly suppress the immune system.
TO NOTE: The above-named nutrients are all important but not an all-inclusive list. For sure there are other important nutrients, like iron, Vitamin A, magnesium, and more, yet we decided to highlight the above to focus as you begin to restore health and wellbeing. Eating all colors of fruits and vegetables (the greater the variety the better) will go a long way, in addition to consuming adequate protein, to getting you up and going.
Staying well hydrated is always important. As we get older, when we are sick and when appetite is low, thirst, or body’s signal that we need to hydrate, is not as accurate at keeping up with our fluid needs. So, like eating, it is a good idea to drink on somewhat of a schedule. Additionally, we actually absorb fluid better when we drink throughout the day rather than have a lot of fluid at once.
Diabetes: Keeping tight blood sugar control is essential to your wellbeing and recovery. Since your weight and muscle mass has changed AND your metabolic reaction to food may have shifted, it is essential you meet with a diabetes educator to help the above recommendations be implemented within the parameter of your needs and blood sugar regulation.
Heart disease, hypertension, pulmonary conditions and other health issues may also require individualized counseling. Ask your local hospital or look online at https://www.eatright.org/find-an-expert> to help find a registered dietitian in your area.
Swallowing challenges called dysphagia, after intubation, is common and may be prolonged in as many as 29% of ICU patients at discharge. For some, post-extubation swallowing disorders have continued up to 4 months after discharge. If you continue to have swallowing issues it is essential to see your doctor as there are modifications to the types and textures of foods that will allow you to get the nutrition you need safely.
A food first approach is always recommended because food provides more than one nutrient and nutrients often work better collectively, rather than in isolation, to keep us healthy. Isolating singular components of food rarely provides the same benefit as when the nutrients in food work in a complementary way to keep our guts healthy and whole-body systems working. There are times however when a supplement might be helpful (as listed in each section above). A quick overview below may also be of help.
A multivitamin/mineral that does not exceed 100 percent of the RDA is safe to take. Look for USP* on the label. Taking a multivitamin-mineral may help make up for some gaps in daily intake of a variety of nutrients yet will not interfere with or create an overabundance of any nutrient. The amount in a multivitamin is not enough to meet a therapeutic dose so if you need more of any one nutrient, consult with your healthcare provider.
Supplement brands with good ratings: Equate [Walmart] Complete Multi 50+; Bayer One A Day Women’s Formula; Nature Made Men’s Multi; Member’s Mark [Sam’s Club] Men 50 + Multi, Thorne, Carlson, Nature Made.
Exercise has the greatest effect on rebuilding endurance and strength and also helps build immune function. Nutritional supplements, especially for those 65 years and older, have marginal or limited effect at best and can only support the effects of exercise, not replace exercise as a means to improve function and ability to participate in activity of daily life. (beaudart, 2017)
Beta-hydroxy-beta-methylbutrate is a metabolite of the amino acid Leucine, and one that seems essential to regulating muscle protein synthesis (may actually slow down muscle breakdown and help stimulate protein building.) A small number of studies has found HMB to increase lean (muscle) mass and some muscle function in older people with or without resistance training. (Cruz-Jentoft) The dose to see a therapeutic effect is 3 grams a day in a powder or pill form for 90 days at least. (Bear)
Supplement Company Brands: EAS; Optimum Nutrition; GNC
Creatine is a naturally occurring protein metabolite stored in our muscles, brain, liver, kidneys and testes. Dietary sources of creatine include meat, fish, and poultry. Creatine supplementation, coupled with resistance/strength training, has been shown to increase muscle size in young athletes. Creatine has also been used to combat sarcopenia (muscle wasting) in older individuals with mixed results. In one study with patients with COPD (chronic obstructive pulmonary disease) creatine supplementation led to increases in fat-free mass, peripheral muscle strength and endurance, health status, but not exercise capacity. (Flud)
Creatine comes in several forms: creatine monohydrate is the preferred form and is safe in moderate doses (3-5 grams a day) and from a reliable manufacturer. It may take three months or more to see positive results. Those with kidney or liver issues should not take creatine. Medications that potentially affect muscle metabolism, such as glucocorticoids and statins may alter the effectiveness of creatine. (Dolan) (Moon)
Brands: GNC, Optimum Nutrition, Dynatize
Polyphenols are plant compounds that are thought to help brain health, protect against heart disease, type 2 diabetes, perhaps cancer amongst other health benefits. Berries (and tart cherries), some herbs, spices (turmeric), dark chocolate and red wine are some foods that are rich in polyphenols.
One important role that polyphenols play is in calming inflammation. Because of COVID, your body is in an ‘inflamed state" as it warded off infection. Now, that inflammation can also have some negative effects on many tissues in your body as well as muscle function.
Tart cherries and tart cherry juice have been studied for their role in helping to calm this inflammation. In one randomized-controlled clinical trial study of men and women ages 65-80, approximately 2 cups of tart cherry juice consumed daily (can be in two or four portions) for 12 weeks reduced several markers of inflammation and oxidative stress compared to a placebo (Chai). 1 oz concentrate is available as well as pill, capsule and powder forms. The juice or concentrate can be made into a smoothie for an enjoyable snack or served alongside a meal. Tart cherry juice has also been shown to help with sleep. The 2-cup portion can cause diarrhea for some so you may want to start with smaller portions and build. (Kuehl) (Nutrients)
Brands: Look for Montmorency cherry juice (not blends as may not have as much of active components), Country Oven, RW Knudsen, or supplements like Cherbundi, Cherry Active as can have concentrated forms vs. drinking full cups.
Recovery will take time. By combining these nutrition rehabilitation guidelines with your physical rehabilitation guidelines, you will be on your way to restored health.
**** We are not recommending which brand to take, and many brand options exist beyond what we have listed. The ones we have mentioned were either ranked high on Consumer Labs testing roundups (consumerLabs.com reviews popular nutrients and supplements). Some content is free and some is subscription based. The "roundups’ send products out for third part testing to see if the product contains what it claims to contain. They will rank product based on cost, claims and available evidence. NSF and Informed Choice both provide third party testing to ensure "purity" (meaning there is nothing other than what is listed on the label in the supplement)- they do not rank products or ensure adequacy in any other way.
DISCLAIMER: These are general nutrition guidelines to help you to continue to recover. This should not override or replace directions from your healthcare provider. If you have any comorbidities or other issues that require more specific attention, please reach out to the appropriate professional for help.
Above Guidelines developed by Heidi Skolnik, MS, CDN with Terry Karl, MS, RD, CDN; MS, Jason Machowsky, RD, CSSD, RCEP, CSCS; Su Xiao, MS, RD,CDN, CDE
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