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 Table of Contents  
Year : 2020  |  Volume : 22  |  Issue : 2  |  Page : 269-270

Nutritional prehabilitation in COVID-19 - “Food for Thought”

1 Phd Scholar, Centre for Community Medicine, AIIMS, New Delhi, India
2 SSO (Health), HQWNC, Mumbai, India
3 Senior Research Officer, National Centre for Excellence and Advanced Research, Centre for Community Medicine, AIIMS, New Delhi, India

Date of Submission01-Dec-2020
Date of Decision11-Dec-2020
Date of Acceptance12-Dec-2020
Date of Web Publication18-Jan-2021

Correspondence Address:
Lt Col (Dr) Neha Singh
Scholar Centre for Community Medicine, AIIMS, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_177_20

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How to cite this article:
Singh N, Ray S, Gupta S. Nutritional prehabilitation in COVID-19 - “Food for Thought”. J Mar Med Soc 2020;22:269-70

How to cite this URL:
Singh N, Ray S, Gupta S. Nutritional prehabilitation in COVID-19 - “Food for Thought”. J Mar Med Soc [serial online] 2020 [cited 2021 Apr 21];22:269-70. Available from: https://www.marinemedicalsociety.in/text.asp?2020/22/2/269/307330

The COVID-19 continues to affect the world with its puzzling inflammatory response, ranging from a very mild disease to extremely intense. It has disproportionately impacted the old and those with comorbidities, especially obesity and diabetes. Race, ethnicity, socioeconomic status, access to health care and increased exposure to the virus due to occupation (frontline health-care workers) have been implicated as critical risk factors.[1] Universal masking and social distancing have been the key concepts for the prevention of the disease with Gandhi and Rutherford[2] hypothesizing that masking has caused variolation which has led to increased number of asymptomatic cases. However, masking alone cannot control the pandemic and social distancing has a negative corollary toward economic activity. Evidence exists regarding building up a strong host immunity in the population through vaccination and nutrition, supplementing each other.

Cytokine storm is a hyperactive immune response to the innate immunity[3] and plays a key role in resistance against entry of novel pathogens. A durable innate immunity can be conferred by a vaccine, or by the presence of myeloid cells (monocytes, macrophages, and neutrophils).[4] On the other hand, the adaptive immunity builds up after the invasion of the pathogen and includes antibody formation to neutralize the virus; killer T cells to destroy the infected cells and the helper T cells to help in the production of antibodies and the killer T cells. Ideally, therefore, training the immune system to elicit a strong innate and adaptive immunity can thwart the infection and its severity.[5],[6] An array of micronutrients, particularly Vit C, Vit D, Zinc, Selenium and probiotics, aid in developing optimal immune response by modulating the secretion of cells such as neutrophils, macrophages and monocytes, required for innate immunity; and B and T lymphocytes for the development of the adaptive immunity.[7]

The effect of nutritional immune-modulation has been witnessed in the last 7 months of COVID lockdown. A healthy host immunity developed by resorting to large scale intake of healthy, nonjunk food along with immunity enhancing supplements, possibly has contributed to lessening the severity of the infection.[8] In contrast, consumption of the Western Diet, an ultraprocessed food, high in saturated fatty acids, omega 6/omega 3 ratio; and low in fiber, might have contributed to dysregulation in innate and adaptive immunity and individuals with obesity, diabetes, and heart diseases, who have suffered the most.[9] Moreover, micronutrient deficiencies are known to be associated with low-grade inflammation such as metabolic syndrome, diabetes and heart failure, conditions known to predispose COVID.[10]

Prehabilitation is a highly effective, graded approach to prevent or reduce the effects of a major surgery, by adding immune-nutrients and exercise to patients who are malnourished, suffering from either nutritional deficiency diseases or excess, by modulating the host immunity.[11],[12] Prehabilitated patients are better placed to cope the postoperative recovery period and safeguard the long-term functional status of such patients.[13] A meta-analysis by Osland et al.[14] found a 20% decrease in postoperative morbidity with a balanced preoperative nutrition in malnourished patients and Hughes et al.[15] found a 34% decrease of postoperative morbidity in prehabilitated patients. Targeted prehabilitation has been studied in diabetes patients with a low carbohydrate, high fat dietary approach, with significant improvements in HbA1C (P < 0.001), fasting glucose (P = 0.006), weight (P = 0.002) and body mass index (P = 0.002). Several other multimodal prehabilitation programs are presently underway successfully.[16]

Recent reviews have recommended early supplementation of Zinc, Selenium, Vitamin C, and Vitamin D to relieve escalation of COVID-19 in high-risk areas and/or soon after suspected exposure of SARS-CoV-2. Furthermore, nutritive adjuvant therapy should be prioritized in high-risk groups, which should be started prior to the administration of specific and supportive medical measures.[17] Patel et al.[18] studied the benefit of Vitamin A and D supplements on humoral immune responses following pediatric influenza vaccination and a higher antibody responses was noted among children who entered the study with insufficient or deficient levels of RBP and 25-hydroxyvitamin D. Researchers have also attempted to propose a protocol for the evaluation and extension of prescribed nutritional support to noncritical COVID-positive patients.[19] Another recent publication to evaluate the current evidence base relating to immunonutrition, with a particular focus on respiratory viruses in target population of above 65 years suggests promising evidence for Vitamins C, D, and zinc and their roles in preventing pneumonia and respiratory infections and reinforcing immunity.[10] A tailor-made, nutritional intervention has a strong possibility to reduce or prevent effects of COVID-19 by favorably enhancing the immune response.

Nutritional interventions are difficult to evaluate when combined with other known interventions to prevent diseases. Prehabilitation programs with dietary and exercise interventions have proven to be highly successful in reducing the severity of major surgeries as well as to reduce complications of diabetes. Improving resilience through a prompt, pragmatic nutritional support is an attractive approach to reduce the severity of COVID as well as speed up recovery in those who suffer from it. An enhanced host nutritional status will also add to the immunity response derived from vaccine. Our approach of prehabilitation is debatable, but to cope with the current crisis, immune supporting micronutrient rich food or supplementation, to the old and those with comorbidities, may allow the global community to “live with the virus.”

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Conflicts of interest

There are no conflicts of interest.

  References Top

Gold JA, Rossen LM, Ahmad FB, Sutton P, Li Z, Salvatore PP, et al. Race, ethnicity and age trends in persons who died from COVID 19 – United States, May – Aug 2020. MMWR Morb Mortal Wkly Rep 2020;69:1517-21.  Back to cited text no. 1
Gandhi M, Rutherford GW. Facial masking for covid-19 – Potential for “Variolation” as we await a vaccine. N Engl J Med 2020;383:e101.  Back to cited text no. 2
Sinha P, Matthay MA, Calfee CS. Is a “Cytokine Storm” Relevant to COVID-19? JAMA Intern Med 2020;180:1152-4.  Back to cited text no. 3
Mantovani A, Netea MG. Trained innate immunity, epigenetics, and covid-19. N Engl J Med 2020;383:1078-80.  Back to cited text no. 4
Stephens DS, McElrath MJ. COVID-19 and the path to immunity. JAMA 2020;324:1279-81.  Back to cited text no. 5
Coen J. An 'uncoordinated' immune response may explain why COVID-19 strikes Some Hard, Particularly the Elderly. Available from: https://www.sciencemag.org/news/2020/09/uncoordinated-immune-response-may-explain-why-covid-19-strikes-some-hard-particularly. [Last accessed on 2020 Oct 16].  Back to cited text no. 6
Derbyshire E, Delange J. COVID-19: Is there a role for immunonutrition, particularly in the over 65s? BMJ Nutr Prev Health 2020;3:100-5.  Back to cited text no. 7
Calder PC. Nutrition, immunity and Covid-19. BMJ Nutrition, Prevention & Health. 2020 May 20:bmjnph-2020  Back to cited text no. 8
Zabetakis I, Lordan R, Norton C, Tsoupras A. COVID-19: The inflammation link and the role of nutrition in potential mitigation. Nutrients 2020;12:???.  Back to cited text no. 9
Zhou Y, Chi J, Lv W, Wang Y. Obesity and diabetes as high-risk factors for severe coronavirus disease 2019 (Covid-19). Diabetes/Metabolism Research and Reviews. 2020 Jun 26:e3377.  Back to cited text no. 10
Gillis C, Buhler K, Bresee L, Carli F, Gramlich L, Culos-Reed N, et al. Effects of nutritional prehabilitation, with and without exercise, on outcomes of patients who undergo colorectal surgery: A systematic review and meta-analysis. Gastroenterology 2018;155:391-410.e4.  Back to cited text no. 11
Durrand J, Singh SJ, Danjoux G. Prehabilitation. Clin Med (Lond) 2019;19:458-64.  Back to cited text no. 12
Carli F, Scheede-Bergdahl C. Prehabilitation to enhance perioperative care. Anesthesiol Clin 2015;33:17-33.  Back to cited text no. 13
Osland E, Yunus RM, Khan S, Memon MA. Early versus traditional postoperative feeding in patients undergoing resectional gastrointestinal surgery: A meta-analysis. J Parenter Enter Nutr 2011;35:473-87.  Back to cited text no. 14
Hughes MJ, Hackney RJ, Lamb PJ, Wigmore SJ, Christopher Deans DA, Skipworth RJ. Prehabilitation before major abdominal surgery: A systematic review and meta-analysis. World J Surg 2019;43:1661-8.  Back to cited text no. 15
Laza-Cagigas R, Chan S, Sumner D, Rampal T. Effects and feasibility of a prehabilitation programme incorporating a low-carbohydrate, high-fat dietary approach in patients with type 2 diabetes: A retrospective study. Diabetes Metab Syndr 2020;14:257-63.  Back to cited text no. 16
Alexander J, Tinkov A, Strand TA, Alehagen U, Skalny A, Aaseth J, et al. Early nutritional interventions with zinc, selenium and vitamin D for raising anti-viral resistance against progressive COVID-19. Nutrients 2020;12:2358.  Back to cited text no. 17
Patel N, Penkert RR, Jones BG, Sealy RE, Surman SL, Sun Y, et al. Baseline serum vitamin A and D levels determine benefit of oral vitamin A and D supplements to humoral immune responses following pediatric influenza vaccination. Viruses 2019;11:907.  Back to cited text no. 18
Caccialanza R, Laviano A, Lobascio F, Montagna E, Bruno R, Ludovisi S, et al. Early nutritional supplementation in non-critically ill patients hospitalized for the 2019 novel coronavirus disease (COVID-19): Rationale and feasibility of a shared pragmatic protocol. Nutrition. 2020 Apr 3:110835.  Back to cited text no. 19


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