Long COVID & malnutrition
30th Nov, 2021

Long COVID Malnutrition 

A recent study published in Nutrients indicates that malnutrition and loss of muscle strength can remain long after the acute phase of the severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection and highlights the need to consider nutritional status in the recovery from COVID-19 (1). 

During the acute phase of SARS-CoV-2 infection, patients are at risk of losing 5-10% of body weight, and malnutrition is common, particularly among hospitalised COVID-19 patients (prevalence of up to 50%) (2,3,4). Malnutrition results from the dual contribution of symptoms that reduce nutritional intake and absorption and systemic inflammation that drives accelerated muscle loss and hypermetabolism (1,5). In addition to malnutrition, patients may present with acute loss of muscle mass and function (acute sarcopenia), which is aggravated by reduced oral protein intake, immobility and prolonged hospitalisation, presence of chronic disease and advanced age (6) (Figure 1). 


Figure 1. Interactions between sarcopenia and COVID-19 (7) CC BY 4.0

Long COVID and malnutrition Figure 1


Many of the signs and symptoms noted to frequently persist after acute SARS-CoV-2 infection, including dyspnoea, fatigue, loss of smell and taste, gastrointestinal issues, and inflammation, can impact and potentially worsen nutritional status (8,9,10). Known as long COVID, these symptoms can persist for more than six months and have been observed in those with asymptomatic, mild, and severe COVID-19 (8). However, the long-term nutritional consequences of COVID-19 are not yet fully understood.

In this prospective cohort study, researchers assessed persistent symptoms, nutritional status, and changes in muscle strength and performance status (PS) 30 days and six months after hospital discharge in COVID-19 survivors (March & April 2020). 

Nutritional status was assessed using BMI and weight loss (%) compared to pre-illness weight, with the Global Leadership Initiative on Malnutrition (GLIM) criteria and French recommendations used to diagnose malnutrition. Muscle strength of arms and legs was evaluated using a self-evaluation of strength (SES), with an SES score

At home 30 days post-discharge (n=288), 136 patients (47.2%) presented with a persistent impairment as assessed by malnutrition (33.3%), and/or reduced muscle strength (SES <7) (26.3%) or limitation of daily activity (performance status ≥ 2 ) (24.3%).

These patients received dietary counselling, nutritional supplementation, adapted physical activity guidance or physiotherapy assistance or were admitted to post-care facilities. 

At 6 months post-discharge (n=119), 36.0% had persistent malnutrition (15.1% with severe malnutrition), 14.3% had reduced muscle strength (SES <7) and 15% had a performance status ≥ 2 .

The most frequent symptoms at 6 months post-discharge were fatigue (16%), psychiatric disorders (mood disorders, anxiety, and post-traumatic stress syndrome) (10%), dyspnoea (7.6%) and neurological symptoms (neuropathy, headache, impaired memory and concentration or cognitive impairment) (4.2%).

Interestingly, in patients with impairment at 6 months, obesity was significantly more frequent than in those without impairment (52.8% vs. 31.0%), and these patients were admitted significantly more frequently to ICU (50.9% vs. 31.3%). Obesity is a common co-morbidity in COVID-19 patients and has been shown to increase the risk for hospitalisation and poorer outcomes (10,11). The current study’s results highlight that obesity may mask malnutrition and muscle loss, increasing the risk of sarcopenic obesity 

There are some limitations to this study. The degree of muscle mass and functional loss may have been influenced by the patient’s pre-COVID medical and functional condition, especially in older adults. Furthermore, the study relied on subjective measures of muscle strength and did not consider confounders, such as micronutrient deficiency (e.g., vitamin D) which may influence muscle condition (13,14).

Regardless of these limitations, the study highlights that nutritional status needs to be considered in the recovery of COVID-19 patients. Therefore, targeted nutritional therapy is required to improve nutritional status, promote recovery, and reduce the risk of late complications. 

1Gérard M, Mahmutovic M, Malgras A, Michot N, Scheyer N, Jaussaud R, Nguyen-Thi PL, Quilliot D. Long-Term Evolution of Malnutrition and Loss of Muscle Strength after COVID-19: A Major and Neglected Component of Long COVID-19. Nutrients. 2021 Nov;13(11):3964.
2Fiorindi C, Campani F, Rasero L, Campani C, Livi L, Giovannoni L, Amato C, Giudici F, Bartoloni A, Fattirolli F, Lavorini F. Prevalence of nutritional risk and malnutrition during and after hospitalization for COVID-19 infection: Preliminary results of a single-centre experience. Clinical Nutrition ESPEN. 2021 Oct 1;45:351-5.
3Di Filippo L, De Lorenzo R, Cinel E, Falbo E, Ferrante M, Cilla M, Martinenghi S, Vitali G, Bosi E, Giustina A, Rovere-Querini P. Weight trajectories and abdominal adiposity in COVID-19 survivors with overweight/obesity. International Journal of Obesity. 2021 May 17:1-9.
4Abate SM, Chekole YA, Estifanos MB, Abate KH, Kabtyimer RH. Prevalence and outcomes of malnutrition among hospitalized COVID-19 patients: A systematic review and meta-analysis. Clinical Nutrition ESPEN. 2021 Mar 17.
5Anker MS, Landmesser U, von Haehling S, Butler J, Coats AJ, Anker SD. Weight loss, malnutrition, and cachexia in COVID‐19: facts and numbers.
6Piotrowicz K, Gąsowski J, Michel JP, Veronese N. Post-COVID-19 acute sarcopenia: physiopathology and management. Aging Clinical and Experimental Research. 2021 Oct;33(10):2887-98.
7Wang PY, Li Y, Wang Q. Sarcopenia: An underlying treatment target during the COVID-19 pandemic. Nutrition. 2021 Apr 1;84:111104.
8Crook H, Raza S, Nowell J, Young M, Edison P. Long covid—mechanisms, risk factors, and management. bmj. 2021 Jul 26;374.
9Proal AD, VanElzakker MB. Long COVID or post-acute sequelae of COVID-19 (PASC): an overview of biological factors that may contribute to persistent symptoms. Frontiers in microbiology. 2021 Jun 23;12:1494.
10Rizvi A, Patel Z, Liu Y, Satapathy SK, Sultan K, Trindade AJ, Northwell Health COVID-19 Research Consortium. Gastrointestinal Sequelae 3 and 6 Months After Hospitalization for Coronavirus Disease 2019. Clinical Gastroenterology and Hepatology. 2021 Nov 1;19(11):2438-40.
11Huang Y, Yao LU, Huang YM, Min WA, Wei LI, Yi SU, Hai-Lu ZH. Obesity in patients with COVID-19: a systematic review and meta-analysis. Metabolism. 2020 Sep 28:154378.
12Yang J, Hu J, Zhu C. Obesity aggravates COVID‐19: a systematic review and meta‐analysis. Journal of medical virology. 2021 Jan;93(1):257-61.
13Piotrowicz K, Gąsowski J, Michel JP, Veronese N. Post-COVID-19 acute sarcopenia: physiopathology and management. Aging Clinical and Experimental Research. 2021 Oct;33(10):2887-98.
14Gkekas NK, Anagnostis P, Paraschou V, Stamiris D, Dellis S, Kenanidis E, Potoupnis M, Tsiridis E, Goulis DG. The effect of vitamin D plus protein supplementation on sarcopenia: A systematic review and meta-analysis of randomized controlled trials. Maturitas. 2021 Jan 12.