INTRODUCTION:

COVID-19 (Coronavirus) disease is a contagious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 is an RNA virus approximately 60-140 nm diameter which has a crown-like structure. It has a concave surface having a higher affinity to the N-terminal helix with ACE2. The COVID 19 is transmitted primarily through the droplets of saliva, discharge of the nose, mouth, or eyes. The virus scatters to the backside of the nasal passage where it binds to angiotensin-converting enzyme 2 which is situated surface of the airway epithelial cell.

It is entered in the lungs through the mucous membrane of the throat and bronchial tube, so it infected type 2 alveolar epithelial cells known as Pneumocytes resulting ARDS (Acute Respiratory Distress Syndrome) that rise in oxidative stress and inflammation¹. The infected patients (80%) will be mildly infected or restricted to the upper airways. The rest of the infected patients (approximately 20%) can develop pulmonary infiltration and some patients may develop severe disease². Particularly older people have been suffering from acute lung infection and ARDS. This stage was recovered by applying airway pressure with oxygen or invasive ventilation; this stage is known to lung consolidation. Endothelial dysfunction in the kidney, liver, brain, heart and lung is occurred by COVID-19 infection³. Due to the declining viral loads in the affected patient, a type of cytokine release syndrome can quickly promote, resulting DIC (Disseminated Intravascular Coagulation) thus, renal dysfunction, liver damage, coagulopathy and death⁴.

High human transmissibility of SARS-CoV-2 has made self-isolation, lockdown and social distancing is a preventive measure to flattening the curve of the disease. Social isolation is an Uncomfortable experience that may have a negative impact on mental health⁵. Effects of self-isolation on emotional equilibrium and psychological, changes in mood and sleep patterns, eating habits, and body weight gain. A well-balanced diet can increase well-being and reduce the negative health consequences of social isolation by aiding in the prevention of chronic diseases (diabetes, obesity), aiding in the management of mood and sleep, and boosting the immune system⁶.

People with a low immune system can attack coronavirus especially overages, pre-existing comorbidities. The immune system is the main key of our body to defend against many health complications like cancers, abnormal cell modification, arthritis, allergies, normal fever, pathogenic infections by viruses and bacteria including COVID-19⁷. We can improve or boost our immune system and also control chronic diseases (e.g. Diabetes, obesity, and hypertension) by providing optimal nutrition. Nutrition modification depends upon the age spectrum. During infancy, breastfeeding fights against various infections and respiratory disease as it contains important antibodies, immunoglobulin, vitamins, enzymes and hormones⁸. In adults, dietary modification is one way to provide strong immunity.

At the individual level, diet is important to prevent viral infections including COVID-19. Specific nutrients, combined nutrients and dietary supplementation may work to the immune system by activation of cells, modification of cell functioning, signalling and gene expression⁹.

Nutrients are classified into two main categories known as micronutrients and macronutrients which play many important roles in the human body. Macronutrients are mainly energy providing food components like protein, carbohydrates, and fat which are essential to regulate the energy need for daily physical work, growth and development, tissues and muscle repairment¹⁰. Vitamins and minerals are known as micronutrients which require small quantities but very essential for the action of disease prevention. During the COVID-19 pandemic, micronutrients obtain high recognition all over the world¹¹. All over the world dietary patterns are different but people can improve their immune function by taking a properly balanced diet. It is also triggering many biochemical reactions like cofactors and coenzymes for metabolism^12,13,14,15.

Almost all documents encourage the consumption of various whole grains, fruits, vegetables, and legume foods. The nutrition society of Italy and Spain has recommended consuming fruits and vegetables not less than 5 servings per day^16,17. Fruits and vegetables are rich sources of various vitamins and minerals like vitamins A, C, D, E and B-complex as well as selenium, zinc, sodium and potassium which are important for the immune system. Fruits and vegetables can control many degenerative diseases like hypertension, diabetes, weight loss and some complications of COVID-19 due to its high-water content, high antioxidant and fibre¹⁸. Free radicals damage occurs in our body when oxidative stress increases and this can be prevented by vitamin C, E, selenium and zinc. Vitamin A, C, D, E, B₆, b₁₂ along with zinc and selenium can support immune response by affecting proliferation, differentiation and function of T and B cells. Trace elements like Zinc, Magnesium, Iron and Selenium play the most important role in enhancing immune response. It is observed that iron can prevent respiratory tract infections in severely infected COVID-19 patients. Fatty acids are structural and functioning component phospholipids which are the building block of cell membranes^19,20.

The target of this review was nutritional guidelines during COVID- 19 and dietary impact to recover from this pandemic situation to provide dietary modification provided by doctors, pharmacists, dieticians and various health care departments. A properly balanced diet may ensure real nutrition like carbohydrates, protein, fat, vitamins, minerals, dietary fibre and water that is essential to growing strong immunity. Until novel coronavirus vaccination completed, taking all precautions and keeping safe and healthy is very crucial.

Carbohydrates, Protein and fat:

Carbohydrates, protein and lipids are the main ingredients to provide energy to the human body both physiologically and psychologically. In the remote past, these three macronutrients have been used in medicine causing fast recovery and digestive system²¹. An adequate amount of carbohydrate intake helps to maintain normal blood sugar level and lowering the body’s stress by modification of immune cells. Scientists have identified a key carbohydrate molecule, called heparan sulfate, that the new coronavirus uses to infect human cells, a breakthrough that could provide a potential new method to prevent and treat COVID19²¹. Heparan sulfate was found in the beef spleen²². Heparin, a kind of heparan sulphate, is currently widely used to prevent and treat blood clots, implying that an already-approved treatment could be repurposed to minimise virus infection. The receptor-binding domain opens up when heparin is bound, increasing ACE2 binding. To enter lab-made human lung cells, the virus must bind to both heparan sulfate on the cell surface and ACE2. Treatment with heparin acts as an antiviral at the dose currently given to the patient²³.

The lack of protein deficiency in the human body can stop the mechanism of primary lymphoid organs (bone marrow, thymus) and generates immune repertories (B and T cell) and suppress the synthesis of IL-6 and TNF-Alpha by bone marrow cells^23,24. Malnutrition can be observed due to insufficient intake of these macronutrients. It is reported that a huge number of COVID-19 cases with a high prevalence of underweight and anaemia can observe many states in India²⁵. Therefore a balanced diet is crucial for preventing various infectious diseases including COVID-19.

Glutamine is a nonessential amino acid that supply energy source for many cells including those maintain in immune responses. It also works on nucleotide synthesis, rapid cell division. During infection, the amount of glutamine consumption through immune cells is equal or greater than that for glucose. Glutamine works many functions of immune cells like neutrophils, macrophages, and lymphocytes²⁶. Tryptophan is an essential amino acid (get only through diet because the body cannot be synthesized) and a precursor of serotonin which regulates our satiety and intake of calories. Thus tryptophan level increases by consuming protein rich foods like meat, fish, milk, yogurt and nuts²⁷. Avoiding refined sugar and consumption of balanced protein will help to fight against inflammation by improving immune function. Older people require more protein than younger and recommended to take at the minimum 1 g/kg body weight to the maintenance of muscle mass²⁸.

Essential fatty acids such as Omega-3 polyunsaturated fatty acids (w3 PUFA) and probiotic are linked to anti-inflammatory and prevent upper respiratory tract infection. A low or short period of physical activity can create a negative effect on physical and mental health. Lockdown can also lead to irregular eating habits, frequent or more food consumption resulting in higher calorie intake and finally developed risk of obesity²⁹. A recent study highlighted age and an inverse correlation between Body Mass Index (BMI) especially young individuals were more probable to have obese who are admitted to hospitals. The study advised that obesity may carry the incidence of COVID-19 cases to younger ages in high prevalence obesity countries. So weight loss or maintain body weight could be a good way to reduce COVID-19 complications³⁰.

Carbohydrates, proteins, and lipids are all broken down into simpler components during digestion. Carbohydrates provide energy (glucose). After fats are broken down into fatty acids, they are used for energy. Protein can be utilised for energy as well, but its primary function is to aid in the production of hormones, muscle, and other proteins. Serotoninergic neurotransmission has been demonstrated to be influenced by dietary carbohydrates, protein, and fat. To find out how they affect spontaneous physical activity, mood, sleep quality, and resting metabolic rate. Physical activity that occurs on its own is an essential factor of energy balance.

Vitamin C and Vitamin E:

Vitamin C, also known as ascorbic acid and it is water-soluble micronutrients. Fruits like oranges, amla, guava, papaya, and kiwi are the richest sources of vitamin C and should be included in our regular diet. Some vegetables like broccoli, spinach, cauliflower, kale, are also good sources of vitamin C which should be included in the diet for its immunity booster’s quality. Spirulina and curcumin should consume the proper amount for elder people, as they are an excessively rich source of vitamin C and other important minerals. These superfoods established strong immunity³¹.

The ascorbic acid is crucial for animal immune responses. It has important functions on antithrombotic, antiviral, inflammatory, antioxidant properties and immunomodulation. Due to pathogenic organisms, an inflammation like sepsis, a life-threatening condition occurs which can be treatable by vitamin C. A recent review discusses the role of vitamin C as a supportive treatment for respiratory infection, sepsis and COVID-19. They also indicate 2-8g/day oral vitamin C may reduce the longevity of respiratory infections and 2-24g/d intravenous vitamin C can decrease mortality, ICU and hospital stay by reducing severe respiratory infections. Vitamin C has a beneficial effect on both the innate and adaptive immune systems. It also reduces reactive oxidative species. Vitamin C enacts a critical role during COVID-19 by downregulates the cytokine storm.

Vitamin E, fat soluble vitamins are maintaining the overall health status of elderly people. It is known as a natural antioxidant. Vitamin E plays a significant role in preventing immune responses. Thus Lack of vitamin E is known to weaken both humoral and cell-mediated immunity³². Low intake or deficiency of vitamin E can alter lipid peroxidation in both in vivo and in vitro and the clinically bad relationship between plasma lipoperoxidase and vitamin E in some patients of ARDS^33,34,35. Oxidative stress is a transport mechanism that develops ARDS as a result of COVID-19. The oxidant-antioxidant imbalance can create excessive lipid peroxidation and ultimately biological membrane damaged^36,37. Vitamin E is found mainly in vegetable-based oils, soaked almonds, peanut butter, pumpkin, sunflower, and soybean oil. So these ingredients should be consumed to achieve the daily needs of vitamin E. Many researchers show interest in vitamin E supplementation during more stress conditions can impaired immunosuppression and oxidative stress³⁸. Globally we all waited for a sufficient supply of vaccines, vitamin E supplementation may improve vaccine efficacy in our society like tetanus and further research may improve the potential benefits³⁹.

Vitamin A and B complex:

Vitamin A or retinol is a fat-soluble micronutrient. Vitamin A also known as retinoid species which can be added through diet in the form of provitamin carotenoids. The most active retinoid is found to be retinoic acid⁴⁰. Vitamin A found in animal sources like meat, fish, egg, cord liver oil and milk as well as plant sources especially orange colour food such as carrots and sweet potato. In our body carotenoids are converted to retinoids⁴¹. The biological function of retinoids is wide including vision maintaining (in the form of retinal)⁴², gene transcription and translation, epithelial cell regulation, bone metabolism and antioxidant properties. It has also immunomodulatory and antimicrobial roles^43,44,45. For these functions, vitamin A may enact an important role in the fight against many viral diseases including COVID-19⁴⁶. Retinoids have been exposed to the development against measles through an interferon-mediated mechanism. Many clinical studies have found increasing host susceptibility to influenza and SARS-CoV virus with a less concentration of vitamin A in various disease models⁴⁷. Oral supplementation of vitamin A doses is presently being investigated for the treatment of COVID-19 besides other antioxidants⁴⁸.

B complex is mainly water-soluble vitamins including B₁, B₂, B₃, B₅, B₆, B₇, B₉, and B₁₂. They play important role in cell metabolism. Vitamin B complex may control cytokine/chemokine secretion and moderate with immune cells interaction involved in pathophysiological route and inflammation⁴⁹. Meat, poultry, fish, milk, cheese, brown rice, legumes and dark green leafy vegetables should be included in our diet for maintaining daily needs and also good immunity⁵⁰. The coronavirus protein has two proteases. They are 3-C-like protease or M-pro and PL-pro (papain like protease) that are first targets in SARS and MERS coronavirus for the discovery of drugs⁵¹. A computational study may allow drug testing using cell-based assay and clinical trials undertaken with B₃, B₉ and B₁₂ being possible challenges that are very important therapeutics in the COVID-19 pandemic but it remains limited. Recently, it was highlighted that folic acid can inhibit furin, preventing binding by the SARS-CoV-2 spike protein thus prevent entry into cell and virus turnover. Therefore it was recommended that folic acid could be useful for the treatment of COVID-19-associated respiratory disease in the primary stages⁵².

Vitamin D and its role:

Vitamin d is a fat-soluble compound that is responsible for the intestinal absorption of minerals such as calcium, magnesium and phosphate⁵³. Vitamin D provides to reduce the risk of microbial infection and death, mainly involving three categories such as physical barriers, cellular immunity and adaptive immunity⁵⁴. Vitamin D3 is synthesised within the skin by the interaction of UVB radiation and 7-dehydrocholesterol. In the liver, Oral vitamin D or D3 is converted into 25(OH)D then converted into 1,25(OH)2D or calcitriol either in the kidney or other desired organ. This calcitriol can create all of the impacts of vitamin D and calcitriol is help to manage the serum calcium concentration. Vitamin D can help to reduce mortality and viral infection including COVID-19⁵⁵. A recent study has highlighted that natural sunlight (source of vitamin D) may quickly inactivate the coronavirus or SARS-CoV-2 on surfaces⁵⁶. A clinical study suggested that the dengue virus can be reduced by giving vitamin supplementation with 4,000 IU/d. it also improves cellular resistance by increasing cytokine storm. Daily consumption of vitamin D can reduce the pro-inflammatory cytokines production and raising of anti-inflammatory cytokines by macrophages^57,58. Supplementation of vitamin D can raise anti-oxidation related genes like glutathione reductase. Recently a study suggested that Low serum 25 (OH) Vitamin-D level was related to a high risk of infectious disease including COVID-19. Currently, the proper serum level of vitamin D available data is very limited which decreases the risk of COVID-19 infection. So further studies are needed to develop the evidence⁵⁹.

Minerals and trace elements:

Minerals or different types of trace elements such as zinc, magnesium, iron and selenium are most important in enhancing human immune response. It is also involved in maintaining the innate and adaptive immune responses, various cell signalling and stimulate the immune cells⁶⁰. Zinc deficiency can inhibit our immunity level by reducing macrophages include phagocytosis and monocytes and also increasing the level of oxidative stress^61,62. The replication of several RNA viruses can be prevented by increasing the level of intracellular zinc (Zn²⁺) concentration. Thus the coronavirus replication may be restricted by raising Zn²⁺ level⁶³. Red meat and shellfish are good sources of zinc so they should be included in our daily diet to improve immunity and health status⁶⁴. Zinc supplementation can minimize up to 52-55%, the severity and time duration of various cold symptoms like sore throat, fever, headache, cough, muscle pain and nasal congestion^65,66,67, which may also happen after SARS-CoV-2 infection.

Magnesium is an important mineral for our immune system. It works as an electrolyte that helps our body to strengthen our immune system through NK cells (natural killers) and lymphocytes. It also helps to provide adenosine triphosphate (ATP) known as an energy source for our cells, which is important because, without this energy, cells cannot function properly⁶⁸. Magnesium helps in the formation of haemoglobin in our blood that is the main compound for delivering oxygen from the lungs to the whole human body. During COVID-19 infection, the virus attacks the respiratory system that time magnesium can help through the oxygen supply into our body⁶⁹. Dark chocolate, black beans, avocados, and whole grains are good sources of magnesium. The trace element magnesium also has a good relation to vitamin D physiology, as it can regulate the hormone level in vivo⁷⁰. This may describe magnesium play a beneficial role between vitamin D and COVID-19 outcomes.

Iron is essential for both health and infection. Iron can produce reactive oxygen species (ROS) by killing pathogens by neutrophils⁷¹. Blood coagulation is commonly observed in COVID-19 patients resulting in death⁷². Iron rich food such as organ meat, liver, spinach, pumpkin seed and brown rice along with vitamin B6 enriched foods are important. Almost 70% of iron is found in haemoglobin form, which helps to carries oxygen into our body⁷³. Sometimes COVID-19 patients face critical problem due to reducing oxygen level. Thus we can overcome this problem by consuming sufficient amounts of iron⁷⁴. A 60mg/day iron consumption can reduce respiratory infection in children⁷⁵. An adequate amount of iron can improve respiratory tract infection, especially in critically infected coronavirus patients. In China, a study of elderly patients showed positive feedback on demands for oxygen support or ICU support was reduced⁷⁶.

An adequate amount of selenium intake can improve immunity and also reduces inflammation, through the synthesis of glutamine peroxidase, which protects to maintain neutrophils from oxidative stress⁷⁷. Selenium deficiency can create heavily pathogenic stains from innocuous strains by RNA viruses mutation⁷⁸.

Lifestyle:

Low physical activity could negatively affect both physical and mental health⁷⁹. Sleep is the most powerful factors to heal and rest our body especially during critical illness⁸⁰. Exercise helps to increase the level of WBC (White Blood Cells) and antibodies which help to fight against infections. Exercise is also important after recovering from illness because it can improve muscle mass and strength of our body. Water is crucial for homeostasis, kidney function or removal of toxin materials, maintaining normal body temperature, mood regulation, gastrointestinal and normal heart functioning and prevention of headache⁸¹. So intake of drinking water and other liquid food like tea, milk, fruits juice should be suggested by dieticians and healthcare members during the COVID-19 pandemic. However daily water requirement depends on body composition, age, physical activity, sex, pregnancy and presence of disease. Excessive alcohol consumption may hamper the immunity system and raises susceptibility to tuberculosis and viral pneumonia in humans and others animals. The Food and Agriculture Organization of the United Nation suggested that intake of alcohol consumption should be limited but not mention specific amounts⁸².

Personal hygiene is very important to combat various infectious disease. Adequate personal hygiene should be needed at the time of food handling and washing hands with soap water or alcohol-based sanitisers. Fruits, vegetable and cooking equipment should be washed properly to free microorganism. SARS-COV-2 can survive on metal or plastic surfaces for 3 days and 1 day on cardboard surfaces. So personal hygiene should be maintained properly to avoid the spreading of coronaviruses.

CONCLUSION:

Nutrients work as a central role in boosting up our immunity and protect from various infection among all age groups. Low immunity can hamper our daily life and peoples are affected more COVID-19. Even deficiency of a single nutrient can compromise immunity and raises more infection whereas a multiple nutrients deficiency can lead more complex situation or issue serious health complication. These health issues we can overcome by consuming a proper balanced diet. Dietary modifications like avoiding simple carbohydrates, intake good quality protein, modification of fat, increased amount of vitamins especially vitamin A, C, D and E and minerals (zinc, magnesium, iron and selenium). A properly balanced diet and adequate amount intake can improve our immune system as well as health status. The proper amount of water and antioxidant should be taken to combat various infectious disease including COVID-19. In this study, we have found a single nutrient, as well as a combination of multiple nutrients, can increases our immunity level. However consume of proper nutrients or diet therapy is not a quick remedy like medicine but we can conclude, diet is a long term remedy that helps to boost up our immunity and also protect us from various diseases including COVID-19.

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Received on 10.08.2021 Modified on 28.12.2021

Research J. Pharm. and Tech 2022; 15(9):4270-4276.

DOI: 10.52711/0974-360X.2022.00717

Minerals and trace elements	Phosphorus	Sodium	Potassium	Copper	Manganese	Selenium	Chromium
Recommended intakes (/day)	1000 mg	2000 mg	3500 mg	1.7 mg	4 mg	40 µg	50 µg

Age group	Calcium (mg/d)	IRON (mg/d)	Zinc (mg/d)	Magnesium (mg/d)
Men	600	17	12	340
Women	600	21	10	310
Pregnant women	1200	35	12	310
Lactating women	1200	21	12	310
Infants	500	46 µg/kg/d	-	30
Children (1-3y)	600	5	5	50
Boys /girls (10-12y)	800	21	9	100/120
Boys /girls (13-15y)	800	32	11	165/210
Boys /girls (16-18y)	800	26	12	195/235