Treatment for COVID Long Haulersby Bashar Khiatah, MD & Amylee Amos MS, RDN, IFMCPLifestyle
The number of COVID-19 cases increases with every new variant, and with those new cases come more and more individuals who are, fortunately, recovering from COVID. Over the last two years, we have learned much about this virus that has impacted the world. Many research studies have been undertaken to understand the symptoms of COVID. Now as modern science has a foundational understanding of the management and treatment of COVID, we need to shift our focus onto the individuals who have survived COVID, but face a high risk of continued health concerns as a result of the disease. COVID survivors have a 75% chance of post COVID symptoms such as fatigue, muscle weakness, sleep disturbance, cognitive dysfunction, and more for months after the acute stage of illness. This is now known as Post-COVID syndrome (1-4). Only time will tell what other long hauler symptoms and conditions may arise even years from now.
The effects seen in COVID long haulers
An infection with the COVID-19 virus induces an aggressive inflammatory response by releasing many pro-inflammatory cytokines in an event described as a "cytokine storm" (5-6). The individual’s immune response to the virus is hyperactive, causing an excessive inflammatory reaction that can be lethal or generate long-term debility after recovery. Whether the response is a storm needing hospitalization or just resting at home, the impact on the body's reservoirs of vitamins, minerals, electrolytes, hormones, and enzymes is substantial (7-10). This impact is often a depletion of these essential elements of maintaining good health status, which explains long COVID symptoms or new-onset diseases post-recovery, including but not limited to cognitive decline, depression, diabetes, hypertension, and fatigue (6). These conditions are unlike the usual pre pandemic versions of these diseases since the root cause is COVID-19 depleting the body's nutrients and breaking down its defense systems. Thus, logically, treatment and approach should be different. 20% of recovered COVID patients had development of fibrotic tissue 9 months post infection (12). In order to recover from COVID, it is essential to maintain persistent downregulation of the inflammasome, the many protein complexes that comprise the innate immune system, in order to mitigate the life altering sequelae and comorbidities related to inflammation as a result of COVID-19. While medication is absolutely needed to immediately control the situation, COVID long haulers treatment must focus on repleting the body's reservoir.
How can COVID long haulers recover?
COVID-19 has been broken down into 4 primary phases: prevention, infection, escalating inflammation, and recovery (12). Each of these phases is inherently different in pathophysiology and target outcome and thus requires different therapies and interventions. The focus of the recovery phase should be focused on resolving ongoing and underlying inflammation, inhibiting tissue damage, avoiding loss of physiological function, and restoring and optimzing physiological function. While medications are often essential during the infection and escalating inflammation phases of COVID, the most powerful interventions for the recovery phase of COVID include lifestyle interventions and therapeutic nutraceuticals. Ideally, as is the case with each phase of COVID, the interventions for recovery should be specific to the individual. Interventions should be tailored based on disease severity, age, sex, comorbidities, and lifestyle. However, given the unprecedented numbers of people recovering from COVID and at risk of Post-COVID syndrome, general recommendations have been documented in the scientific literature, which we have outlined below (12).
Lifestyle Interventions to promote long covid recovery
Modify Your Diet
Diet is a critical point of leverage in COVID recovery. Both through avoidance of inflammatory foods and the inclusion of certain highly therapeutic foods, we can make a significant impact on physiologic recovery. High intake of processed and sugar laden foods contribute to insulin resistance, obesity, and impaired glucose tolerance, all of which are major contributors to systemic inflammation. As a result, a low glycemic diet is indicated, including non-starchy vegetables, fruits, and healthy plant-based fats including extra virgin olive oil.
Additionally, there are multiple mechanisms of potassium wasting in COVID-19, which can result in hypokalemia. Adequate potassium can inhibit inflammation. As a result, increasing potassium levels through the diet is a necessary step in recovery. Healthful foods that are high in potassium and that fit within a low glycemic diet include avocado, spinach, broccoli, plantains, and green bananas.
Diet can also be used to optimize the health of the microbiome. The health of the gut microbiome is intricately connected with overall health. 70% of the body’s immune system resides within the gut microbiome, making it an essential aspect of COVID recovery. Including foods rich in prebiotic fiber such as asparagus, onions, garlic, and jicama, as well as fermented foods when used in conjunction with a low glycemic diet can be helpful in further supporting the immune system.
Intermittent fasting is often recommended as a health promoting intervention. Health practitioners recommend various periods of intermittent fasting depending on the health of the individual and the disease being treated. For Post-COVID syndrome and long COVID recovery, a more mild form of intermittent fasting is best so as not to stress the system (12).
Focus Your Exercise
Exercise is an important modality for improving cellular function and modulating health. The benefits to exercise are vast, so it’s easy to fall into a “more is better” approach when it comes to exercise. However, caution must be taken regarding the intensity and duration of exercise in COVID recovery. Specifically, moderate exercise is highly effective at reducing inflammation. On the other hand, intense exercise can inadvertently have the opposite effect. In intense and prolonged exercise, the skeletal muscle produces interleukin 6 (IL-6). IL-6 upregulates inflammatory processes.
Thus, intense exercise can exacerbate Post-COVID syndrome and prolong unnecessary inflammation. Engage in moderate exercise of about 60-80% exertion (12). Choose exercise activities that feel rejuvenating and energizing rather than overly exerting.
Achieve Quality Sleep
Inadequate and disordered sleep promotes inflammation and inhibits T helper type 1 (Th1) cells. Th1 cells support the antiviral immune response and good quality and adequate sleep supports Th1 cells. Sleep is important to prevent all chronic diseases, but it needs to be especially prioritized in Post-COVID syndrome. Ensure that you allot adequate time to get restorative sleep and practice good sleep hygiene (such as avoiding screens before bedtime, winding down before bed, sleeping in a completely dark room, taking specific sleep promoting supplements, etc.)
Manage Your Stress
Cortisol, the stress hormone, suppresses the immune system. Stress levels are high to begin with in our modern lifestyle. Couple that with a COVID diagnosis, symptoms, and possible hospitalization and stress levels are often off the charts for those with Post-COVID syndrome. Despite these understandable stressors, managing stress levels is imperative, as high stress perpetuates an inflammatory state and leads to a breakdown in function. For COVID long haulers treatment, practice stress management techniques as needed including meditation, mind-body therapies, listening to calming music, soaking in epsom salt baths, and others.
Nutraceutical Interventions for long COVID Recovery
We have outlined a full protocol of COVID Recovery supplements that can be accessed through the Amos Institute Fullscript Dispensary. There you can find our specific brand and dosage recommendations.
Many vitamins, minerals, and botanicals have been investigated with regard to COVID treatment and others have been noted as potentially critical to consider with the need for further research. However, it should be noted that the supplements used to treat COVID vary significantly based on the phase of COVID that the individual is currently in (prevention, infection, escalating inflammation, and recovery). Despite many supplements being hyped in the media as effective and beneficial “for COVID,” the use of supplements is highly nuanced. The supplements we have listed below are of particular importance for treatment of COVID long haulers.
Supplementing Vitamin D
One of the most important vitamins for COVID recovery is vitamin D. Vitamin D levels should ideally need to be at or above 50 ng/dl for optimal recovery. Vitamin D plays a pivotal role in immune system anti-pathogenesis. Deficiency is vitamin D impairs immune function and promotes unnecessary inflammatory reactions. Like all supplements, care should be taken to ensure safety and efficacy. High doses of vitamin D should be taken with vitamin K. Our recommendation for vitamin D can be found here.
Supplementing Vitamin A
Though it doesn’t receive nearly as much attention as vitamin D, vitamin A is of equal importance. Vitamin A deficiency results in impaired immune function, poor antibody production, and overall increased susceptibility to respiratory illnesses (12). Beta carotene, a precursor to vitamin A, is found in orange and red colored plant foods including carrots, sweet potatoes, and butternut squash. Despite beta carotene often being used synonymously with vitamin A, many individuals carry genetic polymorphisms or variants that impair the conversion of beta carotene to vitamin A. Most people do not eat foods that are naturally high in vitamin A, such as liver, and thus deficiencies can occur, dramatically impairing immune function.
For COVID recovery, vitamin A, as opposed to beta carotene, should be taken. For best results and the safest approach, vitamin A should be taken in conjunction with vitamin D and vitamin K. Our recommendation for vitamin A can be found here.
The importance of Resolvins
The omega 3 fatty acids found in fish oil have long been associated with down regulating inflammation. Resolvins, or specialized pro-resolving lipid mediators are downstream byproducts of the fatty acids DHA and EPA found in fish oil. Put simply, the immune system works in two primary phases: initiation and resolution. The human body is designed to undergo both of these phases fluidly and effectively; however, due to a variety of factors, we often do not produce enough pro-resolving lipid mediators to repair the damage caused by the initiation phase of the inflammatory response. Thus the resolution phase is left incomplete, resulting in ongoing tissue damage and loss of function (13).
Supplementing with specialized pro-resolving lipid mediators supports the body’s resilience to the stress of the immune and inflammatory response of COVID. They help repair damaged tissue and reprogram immune cells to be more protective (14). Our recommendation for specialized pro-resolving lipid mediators can be found here.
Additional Vitamins, Minerals, and Botanicals
Many other vitamins, minerals, and botanicals have been studied for their efficacy in treating Post-COVID syndrome. Visit the Amos Institute Dispensary for our full list of recommended supplements and their dosages.
Managing Post-COVID Syndrome
In a perfect world, focusing on COVID prevention is the most ideal intervention. Through vaccinations, wearing masks, social distancing, and avoiding large gatherings we can do much to prevent the spread of COVID. However, millions of individuals have already gotten COVID and sadly millions more will likely get COVID in the future. Fortunately, treatments for COVID and preventative strategies such as the vaccine have made survivability rates increase. Yet even when symptoms seem to have passed, post-COVID symptoms can still arise, leaving many with a long hauler COVID experience. Nutrition, lifestyle, and supplement interventions can help mitigate these post-COVID symptoms and get you back to optimizing your health and feeling your best.
- Davis HE, et al. 2021 DOI: 10.1016/j.eclinm.2021.101019
- Huang C, et al. 2021 DOI: 10.1016/S0140-6736(20)32656-8
- Greenhalgh T, et al. 2020 DOI: 10.1136/bmj.m3026
- Rubin R. 2020. doi:10.1001/jama.2020.17709
- Fajgenbaum DC, June CH. 2020. doi: 10.1056/NEJMra2026131.
- Nalbandian A, et al. 2021 doi: 10.1038/s41591-021-01283-z.
- Shakoor H, et al. 2021 doi:10.1016/j.maturitas.2020.08.007
- Salonia A, et al. 2021 doi: 10.1111/andr.13097.
- Cavezzi A, Tet al. 2020 doi:10.4081/cp.2020.1271
- Alfano G, et al. 2021 doi:10.1007/s10157-020-01996-4
- Camp OG, et al. 2021 doi:10.1016/j.jinorgbio.2021.111546
- Yanuck SF, et al. 2020 PMCID: PMC7190003
- Serhan CN. 2017 doi: 10.1016/j.mam.2017.03.001.
- Souza PR 2020 doi: 10.1161/CIRCRESAHA.119.315506.