Your Guide to COVID-19 Nutritional Rehabilitation: Restore and Replenish

Women’s Sports Medicine Center
Department of Rehabilitation and Performance
Department of Food and Nutrition Services

(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!

START WITH A SCHEDULE

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.

AT HOME

• Before you go home, or once you get home, think through how you will be getting your meals.
• Is there someone who will help prepare food and serve you?
• Can you order-in meals?
• Do you need to work with a social worker to ensure you have the help you need?
• Do you need food assistance?

If so, please access your local food bank:

• United States – https://www.feedingamerica.org/
• New York City – https://www.foodbanknyc.org/
• New Jersey – https://cfbnj.org/
• Connecticut – http://www.ctfoodbank.org/

PROTEIN

• Along with adequate calories, protein-rich foods are the cornerstone to rebuilding muscle. Bedrest and immobility lead to muscle loss which hurts immune function, strength, function, and prolongs recovery.
• Your metabolism has shifted and until restored, it is more difficult to stimulate muscle growth. Age, genetics, physical activity, height and weight all effect how much protein you need and can use.
• As a general guideline, consume 25 to 35 grams of protein at each of your 3 meals and 10-20 grams at each of your 2-3 snacks per day. {Dickinson} See the attached list of foods that provide protein.
• You can mix and match to get enough protein at each meal and snack: for example, include three ounces of turkey and a slice of cheese at lunch and 6 oz of Greek yogurt plus 1 oz of nuts at snack time (van Zanten)
• If you weigh more than 200 lbs., be sure to take in the higher range of recommended protein and include protein with each of your three meals and three snacks as protein needs are based on weight and you might need slightly more than the above recommended amount.

STIMULATE MUSCLE REPAIR

• Muscle protein will be best stimulated if you eat protein throughout the day vs eating a large portion all at once (like waiting to eat a big meal at dinner) so be sure to include protein with each meal.
• Eating adequate protein, coupled with physical training, will result in improved strength over time. In fact, be sure to include a "recovery snack" that includes protein after your daily physical therapy/training for an extra boost in muscle gain.
• You will be working on both muscle strengthening, (essential to build muscle), and cardiovascular training (essential for stamina, heart and lung health). Both types of physical training are important.
• Keep in mind, protein can make you feel full, but protein alone is not a full or complete meal.

Protein Supplements may help you reach your protein goals.

• It is best to try to eat well rounded meals but if you just cannot finish a meal, you may find drinking a ready-to-drink shake is helpful (find in grocery stores , drug stores, or on-line). You may want to use one of these drinks as a snack up to three times a day in between meals until you restore weight and appetite.
• Powered and liquid protein supplements are also available. You can make your own shakes, add ingredients to your liking, or add protein powders to foods like oatmeal, puddings, or even meatloaf to boost the protein. You can also just add powdered milk!
• See attached list of protein supplements, (both ready to drink and protein powders) as well as list of recipes attached to make your own protein smoothies. Additionally, many of the powered protein websites include recipes that you can try with many different flavor profiles.

References for this section: Van Zanten, Katz Webinar, Dickinson

CALORIES

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.

• It is recommended that when you return from the hospital and are trying to restore, you consume at least 35-47 calories per kilogram of bodyweight. (see chart below) [van Zanten]
• Try to consume these calories at even intervals throughout the day instead of undereating during the day and eating a lot at night.

Table: Recommended daily calories by weight

Weight in LBS	Weight in Kg	35 calories/kg	47 calories/kg
115	52.3	1830	2457
125	56.8;	1989	2670
135	61.4	2148	2884
145	65.9	2307	3098
155	70.5	2466	3311
165	75	2625	3525
175	79.5	2784	3739
185	84.1	2943	3952
195	88.6	3102	4166
205	93.2	3261	4380
215	97.7	3420	4593
225	102.3	3580	4807
235	106.8	3739	5020
245	111.4	3898	5234
265	120.5	4216	5661

• This might seem like a lot of food, especially compared to what you were eating before. Once you have restored weight and muscle, you may reduce calories, but for now, you need these calories to build.
• Monitor your weight. This is NOT the time to diet for weight loss! Once your weight has returned to your pre-illness weight; or a stable, reasonable weight if you were overweight, maintain adequate calories. The most important thing to focus on is eating to support restoration, immune function and to regain lean mass. You need the nourishment, strength and building blocks to restore you to health and activities of daily life.

TIPS FOR EATING ENOUGH CALORIES

• Eat three meals
• Eat three snacks
• Save beverages to drink towards end of meal so you do not get a false sense of ‘fluid’ fullness.
• Choose beverages with calories (milk, juice, smoothies) to help add calories if you cannot eat that much. Those are easy to cut back on when you no longer need extra calories.
• Choose calorie-dense foods like breads, muffins, puddings and shakes to add calories.
• Use olive oil, nut butters, and other healthy fats to push calories. For example: dip your bread in olive oil before you eat it like you might in a fine Italian restaurant, coat pasta or rice in oil before adding other sauces or flavorings; sauté vegetables in oil; add nuts to salads, vegetables, yogurts; add jam to toast, chocolate syrup in milk, honey in tea, avocado and/or hummus to a sandwich.

NUTRIENTS THAT SUPPORT IMMUNE FUNCTION

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

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.

• Due to the stress on your body as you restore strength and build, there is some evidence to support, 200-500 mg a day from food (or supplement) to ensure your tissues reach saturation with the health benefits of Vitamin C.
• This amount is certainly safe. However, taking supplemental Vit. C in doses higher than 1000 mg (or 1g) will actually lower the amount you absorb and may cause gastrointestinal distress e.g. diarrhea, nausea, abdominal cramps, etc.
• The tolerable upper limit for Vitamin C intake from supplements is set at 2,000 mg (or
• 2 g) per day.
• Supplements come in pill or powdered form. Bronson Laboratories was found to be the least expensive in powdered form and you can easily adjust the amount you want to take. (ConsumerLab). Thorne, Nature Made and Trader Joe’s brands are a few that have been certified by NSF, Informed-Choice.org, or ConsumerLab.com.

Eating whole foods is preferred to supplements because:

• there are lots of other protective nutrients in fruits and vegetables in addition to the Vit C they provide
• there are no absorption benefits to a supplement
• there are no calories in a supplement, which you now need (Supplements remain an option if you are on a very limited diet.)

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

The US Department of Agriculture’s (USDA’s) Food Data Central lists the nutrient content of many foods and provides a comprehensive list of foods containing vitamin C arranged by nutrient content and by food name. https://ods.od.nih.gov/factsheets/VitaminC-HealthProfessional/ 

Consumerlab.com Answers

ZINC

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.

• Symptoms of deficiency include impaired immune function, hair loss, diarrhea, taste abnormalities, loss of taste, impotence and delayed wound healing.

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:

• Adult Men (19 and older): 11 mg
• Adult Women (19 and older) 8 mg

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

https://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/

Zinc Supplements

• Overall, the type of zinc is not as important as the amount you take.
• A typical multi-vitamin/mineral supplement will provide 5-10 mg so if you are trying to ensure adequate intake along with food, a multi vitamin mineral is sufficient.
• If you are deficient, then a 20 mg-40 mg daily zinc supplement may be indicated for two weeks.
  • Zinc gluconate is typically the least expensive
  • Zinc bis-glycinate may be easier to absorb
• Take a zinc supplement separate from milk or high fiber foods as they may interfere with absorption. Medications that reduce stomach acid (Prilosec or Pepcid), and certain medications for high blood pressure such as ACE inhibitors, and thiazide diuretics ("water pills"), may increase zinc needs.
• Taking zinc can interfere with penicillamine (used to treat rheumatoid arthritis).
• Vegetarians may also need as much as 50 % more zinc as the phytates and fiber in plant-based foods may interfere with zinc absorption.
• Excessive alcohol intake interferes with zinc absorption.
• Reputable brands include but are not limited to: Nature Made, Solgar, Xymogen, Pure Encapsulations, Thorne.

https://ods.od.nih.gov/pdf/factsheets/Zinc-Consumer.pdf 
Consumer Lab Zinc Supplements and Lozenges Review

VITAMIN D

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.

• The Vitamin D our bodies use can actually be made by our skin with the ultraviolet light from the sun! This is one reason why getting outside for at least three times a week for 30 minutes (with exposure on your hands, arms, legs and face) is helpful and recommended. It is also found in some foods. However, as we age, we may not convert the active form of Vitamin D from the sun as well. Overweight and obese individuals may also have lower levels of serum Vitamin D. There may be different (lower) optimal Vitamin D levels in African Americans for bone health but it is unknown if this applies for immune function. (Wright)
• Vitamin D recommendations are expressed in either IU (International Units) or as mcg (micrograms). The Recommended Daily Amount of Vitamin D per day is 600 IU (15 mcg) from ages 1-70 and 800 IU (15 mcg) for 71 years and older. However, recent research indicates that we may need more.
• See the food sources of Vitamin D below. As you can see, the food supply of Vitamin D is rather limited. Supplementation is often needed

Table: Selected Food Sources of Vitamin D

Food*	Micrograms (mcg) per serving	IUs* per serving
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

https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional

How do you know if you have enough Vitamin D?

• Ask your doctor to check your Vitamin D level. If your vitamin D levels are low, you may be advised to take a higher dose of vitamin D until your levels increase to a normal range (usually over a number of weeks or months). Your vitamin D level should be monitored regularly by your physician to adjust the supplement appropriately.
• Refer to the table below for blood (serum) Vitamin D levels recommended by the National Institute of Health (NIH). Basically, the goal is to have levels between 30-50 nmol/L . Levels between 40-60 nmol/L may be appropriate as recovering from Covid. (Grant)
• When comparing your vitamin D levels to the table below, please ensure you are looking at the right measurement value (nmol/L or ng/mL) from your test.

Table: Serum 25-Hydroxyvitamin D [25(OH)D] Concentrations and Health*

nmol/L**	ng/mL*	Health status
<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)

* Serum concentrations of 25(OH)D are reported in both nanomoles
per liter (nmol/L) and nanograms per milliliter (ng/mL).
** 1 nmol/L = 0.4 ng/mL

https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

Vitamin D Supplementation

• Since many people work indoors or in parts of the country with limited sun (think North in the winter), and getting enough from food is not always realistic, taking a daily of supplement 400-800 IU is often necessary to maintain healthy levels of serum (blood) Hydroxyvitamin D [25(OH)D].
• If your blood levels are low, you may need higher amounts to bring your Vitamin D.
• status up. Taking 1000 - 2,000 IU a day is reasonable with follow up determined by your physician on appropriate dosing based on your blood levels.
• It is probably best not to take more than 2000 IU/day without being seen by a physician as too much vitamin D can lead to complications as well. The upper limit for supplementation is 4000 IU (unless prescribed by your doctor).
• Take your supplement with food, preferably one that has fat in it as this will boost absorption. You can take the entire amount at once; it does not have to be in divided doses.
• Vitamin D2 or D3 both work yet Vitamin D3 is best absorbed.
• Nature Made, Whole Foods, Garden of Life, Pure Encapsulations are among brands that have been certified by NSF, Informed-Choice.org, or ConsumerLab.com or have USP on their label.
• If you are having trouble taking pills, try Source Naturals Vitamin D-3 liquid drops, rated highest in Consumer Labs review.
• Steroid medications, such as prednisone, can reduce calcium and Vitamin D metabolism.

Jolliffe DA, Grant, McKee, Wright
https://www.consumerlab.com/reviews/vitamin_D_supplements_review/Vitamin_D/
https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

Jolliffe DA, Greenberg L, Hooper RL, et al
Vitamin D to Prevent
https://ods.od.nih.gov/factsheets/VitaminD-Consumer/

GUT HEALTH AND PRE/PROBIOTICS

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.

• Probiotics are 'good strains' of microorganism/bacteria that can help us in a variety of ways. There are different strains of probiotics, each may have a distinctive effect on our health from helping with or reducing the risk of diarrhea, constipation, upper respiratory infection, even acne! The most common are bacteria that belong to groups called Lactobacillus and Bifidobacterium. Other bacteria may also be used as probiotics, and so may yeasts such as Saccharomyces boulardii. If a specific kind of Lactobacillus helps with preventing an illness, that doesn’t necessarily mean that another kind of Lactobacillus or any of the Bifidobacterium probiotics would do the same thing.
• Probiotics are found in fermented foods like yogurt (with active cultures), even soy yogurt if it has active cultures, kefir (you can use this to make shakes! Evolve, Lifeway and Latta are three name brands with high active cultures), pickled vegetables, tempeh, kombucha tea, kimchi, miso, and sauerkraut. Even eating one yogurt a day with active cultures (it will say so on the label) is very helpful.
• Prebiotics are the food that Pro-biotics live on. Pre-biotics are found mostly in fruits, vegetables, beans and whole grains. Eating these foods helps to keep a healthy digestive track as part of a healthy immune system.
• A probiotic supplement may or may not be helpful. Because there are so many different strains, it may be difficult to know which to take. If you are already immune suppressed, taking a probiotic supplement may even be harmful, whereas eating pre and pro biotic foods would only be helpful. Talk with your healthcare provider about whether taking a supplement is a good idea and if so, which one is best based on your symptoms (diarrhea, upper respiratory tract, overall immunity…) Popular brands like Culturelle and Visbiome are top picks according to ConsumerLabs.

https://www.consumerlab.com/reviews/Probiotic-Supplements/probiotics/#results

OTHER NUTRIENTS NEEDED

CALCIUM

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!

• Calcium foods are essential to help keep the bone mass you have. Getting in 1000 -1200 mg each day of calcium, also in divided amounts throughout the day, for bone health is imperative. Your body can only absorb 500 mg of calcium at one time.
• Use the Calcium Calculator (separate document attached) to figure how much you get daily from food (or identify how you can increase to meet goal). What you do not consume in food, you should match in a supplement. A food first approach is recommended but if you need to supplement your intake, take only what you need to reach the 1000-1200 mg goal. Try buying a 250 mg supplement so you can easily add calcium in an incremental amount to make up for food.
• Calcium Citate may be easier on your stomach. Gummies, tablets, or even calcium chocolates are all options. Nature Made, Thorne, Citracal, Caltrate, Viactiv, Solgar and Jarrow are all reputable brands.

OMEGA 3 FATTY ACIDS

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.

• There are three types of omega 3 fatty acids:
  • alpha-linolenic acid (ALA)found primarily I plants such as flax, chia, nuts, seeds and oils. ALA can be converted to EPA and DHA in the body, but it is unknown how much actually converts.
  • The RDA (recommended daily allowance) for ALA for women is 1.1 g and for men is 1.6 g (see food sources below)
  • Eicosatetraenoic acid (EPA) and docosahexaenoic acid (DHA) are the most important fats to help with overall brain health and to promote anti-inflammatory processes in the body. EPA and DHA are primarily found in fatty fish and shellfish.
  • The Academy of Nutrition and Dietetics recommends at least 500 mg of EPA and DHA daily for adults.
• Recommendations suggest aiming for consumption of fatty fish two times a week plus a handful of nuts several times a week. Additionally, omega 3 fatty acids can be added to other foods as a "fortification" such as some brands of juices, eggs, yogurt and milk or milk-substitute beverages. Foods rich in omega 3 fatty acids include:

Table: Selected Food Sources of ALA, EPA, and DHA

Food	Grams per serving
	ALA	DHA	EPA
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

*Except as noted, the USDA database does not specify whether fish are farmed or wild caught.
**The USDA database does not specify whether beef is grass fed or grain fed.

 

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.

• Omega 3 Supplement brands: Nordic Naturals, Thorne, GNC, Omega Infusion, Nature made, Nutrigold (krill), Pure Encapsulations.
• Lastly, it is important to note there are other types of "healthy fats" besides omega 3’s that can be helpful – specifically monounsaturated fatty acids (MUFAs). Examples of these foods are olive oil, avocado and many nuts/peanuts and seeds.
• Try to include reasonable portions of omega 3 and MUFA-rich foods in your daily meals or snacks. Use olive oil as part of a salad dressing, or to sauté vegetables or even dip bread in. Make almonds (or other nuts) part of your snack with some dried apricots, add to sautéed vegetables, or sprinkle of yogurt or oatmeal. Salmon can be baked, grilled or poached with or without seasoning and eaten as an entrée, on a salad, and even as part of breakfast!

https://ods.od.nih.gov/factsheets/Omega3FattyAcids-Consumer/
https://ods.od.nih.gov/factsheets/Omega3FattyAcids-HealthProfessional/
Rockwell and Ritz

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.

HYDRATION

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.

• Drink with each meal (we absorb better when we have some food in our stomachs!) and aim to consume about a cup to two cups of fluid in between meals. All fluid counts, not just water so if you are drinking shakes, water, juice, milk, or tea, they will all count toward keeping you hydrated.
• If you urinate every three to four hours and your urine is of good volume, you are probably doing a good job staying hydrated! If your urine is dark colored (think apple juice) and dense, not of good volume, then you probably need to step up your hydration efforts.
• If you are experiencing diarrhea or vomiting, you may need to take in more fluids to rehydrate and replace electrolytes lost. Try an oral hydration beverage like Pedialyte, Gatorade, Boost-Breeze, or a different option your healthcare provider recommends.

OTHER HEALTH ISSUES THAT MAY NEED FURTHER ATTENTION

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.

ESPEN Barazzoni https://doi.org/10.1016/j.clnu.2020.03.022

SUPPLEMENTS TO CONSIDER

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.

Multi vitamin/mineral (tab, gummy or liquid)

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.

* The USP Verified Mark is awarded by USP (United States Pharmacopeia) to dietary supplement products that successfully undergo and meet the stringent requirements of its voluntary USP Dietary Supplements Verification Process. The USP Verified Mark on the label indicate that the product:

1. contains the ingredients listed on the label, in the declared potency and amount
2. does not contain harmful levels of specified contaminants
3. will break down and release into the body within specified amount of time
4. has been made using safe, sanitary and well-controlled manufacturing practices according to FDA and USP guidelines

SUPPLEMENTS THAT SUPPORT MUSCLE BUILDING AND RECOVERY

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)

HMB

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

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

Tart Cherry (Montmorency cherries) Juice

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.

CONCLUSION/SUMMARY

Recovery will take time. By combining these nutrition rehabilitation guidelines with your physical rehabilitation guidelines, you will be on your way to restored health.

• Consuming adequate protein at every meal is essential.
• The nutrients in whole foods work in synergy to support your immune health and promote overall health.
• Choose calcium rich dairy or dairy alternatives, nutritious fats like olive oil, nuts, avocado and fish, plenty of fruits and vegetables rich in Vitamin C and other nutrients that will help keep you healthy along with beans and whole grains.
• Make sure you are getting enough Vitamin D to keep your levels in the appropriate range.
• These are the foods that will also support a healthy gut environment to reduce further risk of infection and maximize absorption of the good nutrients you are eating.
• Consider if supplements make sense for you.
• Continue to wash your hands regularly, get adequate sleep and maintain social distancing. Consult with your health care provider on a regular basis to assess your progress.

**** 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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