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Tools in addressing Long Covid

October 22, 2021

Herramientas en el abordaje de Long Covid

Coronaviruses are a type of RNA virus that have a great capacity to adapt to other species and are highly variable. The pandemic began in December 2019 in Wuhan, China, where the virus we today call SARS-CoV-2 was detected. Due to their S proteins (what we call “spike”, like small barbs) are anchored to our cells in order to proliferate. Unlike other viruses such as SARS or MERS, this virus is less lethal, however it has an affinity between 10-20 times higher than SARS-CoV-1 and has a much higher reproduction rate than other coronaviruses.

This virus is capable of entering our body through receptors, “doors” called ACE2 located in our cells, where the virus anchors. These receptors are in high quantities in type I alveolar cells and type II gastric cells and enterocytes, in the liver and bile ducts.

COVID-19 infection has multisystem effects, including systemic inflammation, immune dysregulation, activation of the hypothalamic-pituitary-adrenocortical axis leading to immunosuppression and lymphopenia, a hypercoagulable state, encephalopathy and encephalitis, and systemic organ failure (Iadecola et al. al. 2020).

What do we talk about when we talk about long Covid?

Although 33-45% of COVID-19 infections are asymptomatic, some people suffer sequelae and other health problems that persist for more than 4 to 6 weeks.

10/20% (some studies point to up to 15-20%) suffer from what we call Persistent COVID or Long COVID: these people do not fully recover after 4 weeks and remain with symptoms that disable them, affecting their quality of life. Middle-aged women and men with associated comorbidities around 70 years of age are those who most predominate in LC. The most persistent and even disabling symptoms are:

  • Asthenia/Fatigue
  • General discomfort
  • Lack of concentration and memory
  • digestive disorders

What are the hypotheses behind Long Covid?

We still lack a lot of information and some symptoms cannot yet be given an exact explanation, however there are several hypotheses:

  1. We know that once overcome, viral remains can persist in the olfactory mucosa or intestinal mucosa, causing chronic inflammation due to the activation of the immune system and the virus.
  2. Cytokines are inflammatory messengers that our body produces when faced with an infection. If they are produced in excess, what we call a cytokine storm, this causes higher levels of inflammation and damage to tissues and organs. It is very common in Covid and especially in people with high levels of inflammation, since the immune system presents an aberrant reaction.
  3. Presence of autoantibodies that can act against immunomodulatory proteins and therefore our body cannot resolve this inflammation.
  4. Mitochondrial involvement and oxidative stress: the cytokine storm generates oxidative stress and therefore affects the membrane of the mitochondria, the organelle with which we are capable of producing energy.

The more inflammation that has occurred during the infection, the worse the recovery will be and the more likely we will be to suffer sequelae. We know that people with hypertension, diabetes, obesity, insulin resistance and smokers, among others, aggravate the conditions and increase the risk of suffering from a much more serious covid, therefore, although genetics is another factor, we know with certainty. certainty that our lifestyle can help us prevent the risk of contagion, have a much milder COVID and recover sooner.

For example, according to a meta-analysis published in Medrxiv concludes that adequate levels of Vitamin D lead to a significant decrease in mortality from infection and a lower rate of admission to the intensive care unit (ICU), in addition to a decrease in inflammatory markers.

Also, a work by Salgado-Aranda published by members of the San Carlos Clinical Hospital in Madrid (2021) observed that a sedentary lifestyle increased the risk of mortality from COVID-19 by 6x.

Another narrative review concludes that Zinc inhibits the replication of viruses such as SARS-coronavirus, hepatitis C, hepatitis E and influenza H1N1. Zinc can also inhibit RNA-dependent RNA polymerase, stopping virus replication in the host. Zinc levels are typically low in septic patients and are inversely correlated with disease severity and the presence of proinflammatory cytokines such as IL-6, IL-8, and TNFα.

As we see, these are just some of the many studies that show that nutrition and lifestyle can make a clear difference in how we overcome this infection and our ability to recover.

What can I do then to improve long covid?

First of all, we must remember that we must go to our doctor so that they can properly monitor our case, since each person has different conditions and symptoms and therefore, the approach will be different.

Secondly, we must keep in mind that apart from the physical symptoms, we must pay attention to mental health. Many patients suffer from post-traumatic stress, anxiety and depression due to fear of contagion and also due to social distancing. The anguish, loneliness, sadness and helplessness of the situation caused by this pandemic must be taken into account to treat the patient in a more holistic and integrative way. The support of a psychologist for people who suffer from this type of mental health problems should be essential for the patient's improvement.

Finally, anti-inflammatory nutrition will help us recover and strengthen our immune system against possible new infections.

Reducing meals to 2 or 3 a day and intermittent fasting for 14 to 16 hours may also help reduce inflammation levels.

We would recommend avoiding processed foods high in sugar, focusing on each dish consuming quality proteins (egg, meat, fish, dairy products...), healthy fats (avocado, olive oil, olives, coconut oil, small blue fish...) and low glycemic index carbohydrates (tubers, quinoa, buckwheat...). The consumption of cruciferous vegetables, grapes, onion, green tea, ginger, turmeric and red fruits will help reduce NF-kB levels and regulate inflammation.

Due to the inflammatory cascade caused by COVID 19 and that the majority of patients in Europe have unbalanced levels of Omega 3 in order to resolve the inflammation, we see the administration of 4 to 10g of the active ingredient of Omega 3 daily, 60% EPA, as beneficial. and 40% DHEA.

It would also be advisable to administer vitamin D, which is highly deficient in the world population, to help our immune system resolve inflammation, reduce blood pressure , regulate sugar levels, among many other benefits. Supplementation with Magnesium will be important, since vitamin D generates depletion of this mineral, which is key in the metabolism of vitamin D so that the VDR cellular receptor is expressed, so that vitamin D binds to the binding protein and to synthesize 25-OH D and 1.25 (OH). It is recommended to evaluate the levels of minerals and vitamins such as selenium, zinc, iron, copper, etc. on an individual basis.

Finally, we recommend performing controlled aerobic exercise and, above all, strength training to recover the lost muscle mass that usually occurs due to inactivity and infection, in addition to the multiple benefits in regulating the immune system, impacting mitochondrial health and the metabolism in inflammation.

Without a doubt, the holistic and individualized approach to the patient is essential for a resolution of symptoms and an improvement in quality of life.

If you want to remedy fatigue and other symptoms related to long-covid, request your appointment here .

Sources

Garner P. Covid-19 and fatigue—a game of snakes and ladders. BMJ Blogs, May 19, 2020. https://blogs.bmj.com/bmj/2020/05/19/paul-garner-covid- 19-and-fatigue-a-game-of-snakes-and-ladders/ (accessed Dec 10, 2020).

Wood E, Hall KH, Tate W. Role of mitochondria, oxidative stress and the response to antioxidants in myalgic encephalomyelitis/chronic fatigue syndrome: A possible approach to SARS-CoV-2 'long-haulers'? Chronic Dis Transl Med [Internet]. 2021;7(1):14–26. Available from: https://www.sciencedirect.com/science/article/pii/S2095882X20300839

Cashman KD, Dowling KG, Škrabáková Z, Gonzalez-Gross M, Valtueña J, De Henauw S, Moreno L, Damsgaard CT, Michaelsen KF, Mølgaard C, Jorde R, Grimnes G, Moschonis G, Mavrogianni C, Manios Y, Thamm M , Mensink GB, Rabenberg M, Busch MA, Cox L, Meadows S, Goldberg G, Prentice A, Dekker JM, Nijpels G, Pilz S, Swart KM, van Schoor NM, Lips P, Eiriksdottir G, Gudnason V, Cotch MF, Koskinen S, Lamberg-Allardt C, Durazo-Arvizu RA, Sempos CT, Kiely M. Vitamin D deficiency in Europe: pandemic? Am J Clin Nutr. 2016 Apr;103(4):1033-44. doi: 10.3945/ajcn.115.120873. Epub 2016 Feb 10. PMID: 26864360; PMCID: PMC5527850.

Liu Z, Xiao X, Wei X, Li J, Yang J, Tan H, et al. Composition and divergence of coronavirus spike proteins and host ACE2 receptors predict potential intermediate hosts of SARS-CoV-2. J Med Virol. 2020;92(6):595–601.

Spanish Association of Physiotherapists in Primary Care and Community Health. Recommendations for physiotherapy care for patients affected by COVID-19 infection from primary and community care. 2020; Available from: http://www.aefi.net/Portals/1/coronavirus/Recommendations Fisioterapia APySC patients affected by COVID19.pdf

Smondack P, Gravier F, PRieur G, Repel A, Muir J, Cuvelier A, et al. Kinésithérapie et COVID-19: from reanimation to home rehabilitation. Synthèse des recommendations internationales. Ann Oncol [Internet]. 2020;37:811–22. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7552976/pdf/main.pdf

O'Sullivan O. Long-term sequelae following previous coronavirus epidemics. Clin Med. 2021;21(1):e68–70.

Mohamed AA, Alawna M. Role of increasing the aerobic capacity on improving the function of immune and respiratory systems in patients with coronavirus (COVID-19): A review. Diabetes Metab Syndr Clin Res Rev [Internet]. 2020;14(4):489–96. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7186129/pdf/main.pdf

Lutchmansingh DD, Knauert MP, Antin-Ozerkis DE, Chupp G, Cohn L, Dela Cruz CS, et al. A Clinic Blueprint for Post-Coronavirus Disease 2019 RECOVERY: Learning From the Past, Looking to the Future. Chest [Internet]. 2020;159(3):949–58. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medp&NEWS=N&AN=33159907

SEPARATE. Respiratory physiotherapy in the management of patients with COVID-19: General recommendations. Version 03/26/2020. 2020; Available from: https://www.sermef.es/wp-content/uploads/2020/04/Guía-general-fisioterapia-respiratoria.-SEPAR.pdf

Office for National Statistics. The prevalence of long COVID symptoms and COVID-19 complications. Dec 16, 2020. https://www.ons.gov.uk/news/statementsandletters/theprevalenceoflongcovidsymptoms andcovid19complications (accessed Dec 16, 2020).

Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. B.M.J. 2020; 370: m3026.

Puntmann VO, Carerj ML, Wieters I, et al. Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19). JAMA Cardiol 2020; 5: 1265–73.

Libby P, Luscher T. COVID-19 is, in the end, an endothelial disease . Eur Heart J 2020; 41: 3038–44.

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