Long COVID: Mediterranean Diet Guide

Nutrition and Long COVID

The quality of food is critical to your overall health. A healthy diet balances the good vs. bad bacteria in the gut helps reduce inflammation in the body and enhance immune system functioning.

Nutrition is one of the pillars in the approach to managing long COVID. The food you eat can help lessen symptoms, reduce complications, and improve recovery.

Intestinal Microbiota

Your diet affects the bacteria in your intestines (the intestinal microbiota) which in turn impacts your health. A key factor in the way diet affects the gut microbiome (the overall environment of the gut) is the fiber in your diet. Fiber nourishes and enhances the growth of anti-inflammatory bacteria in your gut.

Several studies suggest that COVID-19 may promote an imbalance of the microbiome. To counteract this effect, you can change your diet to help increase the “good” and decrease the “bad” bacteria in your gut. Within days your gut microbiota may be more balanced.

Based on the current evidence, there is no specific diet that prevents or cures COVID-19 infection or long COVID. However, adopting a diet with the strongest anti-inflammatory effect is a logical approach.

Such a diet consists of a variety of plant-based foods (this does not mean a vegetarian or vegan diet) and a healthy balance of fats and high-quality protein. It provides a steady supply of long-lasting energy and reduces inflammation-promoting chemicals in your body.

There aren’t specific recommendations for the use of supplements for long COVID, however, there are vitamins and minerals from healthy food sources that help improve immune system function and the symptoms of long COVID. 

Mediterranean Diet and Brain Health

The Mediterranean diet, which is a type of anti-inflammatory diet, is based on traditional eating patterns of countries surrounding the Mediterranean sea, like Greece, Spain, and Italy.

There seems to be a positive connection between the Mediterranean diet and better brain health. Research shows that the Mediterranean diet has a protective effect on the brain. It is associated with a decrease in cognitive decline and a lower risk of cognitive impairment.

The diet has a high proportion of fruits and vegetables (phytonutrients); a moderate amount of chicken, fish, eggs, and milk products; and minimal red meat and processed foods. It also includes healthy fats (e.g. omega-3 fatty acids), vitamins and minerals (micronutrients), and fiber. 

Foods To Include Vs. Foods To Limit 

What About Nightshade Vegetables and Inflammation?

Nightshade vegetables include tomatoes, eggplant, bell peppers, potatoes, and the spices paprika and cayenne pepper. 

Some people think nightshade vegetables trigger flare-ups of inflammatory conditions. The truth? There isn’t any evidence of a link between these foods and inflammation, however, some people may be sensitive to them.

If you think the nightshades worsen your symptoms, avoid them for two weeks, and see if your symptoms improve.

Do Low Histamine Diets Help With Recovery From Long COVID?

Histamine is a substance produced by cells as part of the immune system response to viruses, substances, etc. It increases inflammation, thus it can cause or worsen certain symptoms. It has been suggested that this type of immune system response may play a role in long COVID. 

Histamine occurs naturally in food. A low-histamine diet has been promoted to help reduce long COVID-related inflammation and other symptoms.

For some people with actual food histamine intolerance, the diet may be recommended. However, there is little evidence to support its effectiveness in people with long COVID.

Before Considering A Low-Histamine Diet

In addition to the lack of evidence to support the effectiveness of the low-histamine diet for long COVID, the following are also potential considerations:

  • The diet is time-consuming and difficult to follow

  • There isn’t a test to diagnose food histamine intolerance

  • The process requires 2 to 4 weeks of eliminating, then gradually reintroducing foods to check for symptoms. It should be supervised by a dietitian or another healthcare provider.

  • It limits many healthy foods

  • Much of the available information about following the diet is conflicting

High-Histamine Foods

There is mixed information about what is considered a high-histamine food. The following are high-histamine foods:

  • Fruit: avocado, citrus fruits, strawberries, kiwifruit, papaya, pineapple, dried fruits

  • Vegetables: tomatoes, spinach, eggplant

  • Protein: fish (e.g. mackerel, tuna, sardines, anchovies, herring), eggs, aged beef, cured meats (e.g. salami, ham), meat or fish that is a leftover

  • Dairy: aged cheeses (cheddar, gouda, Roquefort, parmesan), yogurt, kefir

  • Fermented foods: vinegar, sauerkraut, kimchi, miso (fermented soybeans)

  • Other: nuts, chocolate

  • All alcohol

Healthy Meal Ideas

When you prepare your own meals, you can include healthy foods and avoid unhealthy ones. Here are some examples to get you started.

Breakfast

  • Eggs

    • 2 hard-boiled eggs with ½ avocado on 1 slice of whole-grain bread - rye, barley, or sourdough bread

    • 2 scrambled eggs with turmeric

    • 2 poached eggs with smoked salmon and avocado

  • Oatmeal (rolled and steel-cut oats are higher in fiber than quick oats and less processed) with:

    • ½ cup (120 g) of berries and 2 tablespoons (20 g) of sunflower seeds

    • ½ cup (120 g) of unsweetened applesauce, 2 tablespoons (20 g) chopped almonds, and a dash of cinnamon, nutmeg, or pumpkin pie spice for extra flavor

    • ½ teaspoon (2.5 g) unsweetened cocoa powder and 1 teaspoon (5 g) of nut butter

  • Cocoa chia pudding (cocoa powder with chia seeds mixed together with any type of milk, and refrigerated overnight) with, 2 tablespoons (20 g) of chopped walnuts, ½ cup (120 g) of raspberries

  • Energizing protein smoothie with 1 tablespoon (15 g) unsweetened cocoa powder, ½ cup (120 mL) almond milk, 2 tablespoons (20 g) peanut butter or almond butter, ¼ cup (60 g) oats, 1 to 2 tablespoons (15-20 g) flaxseed, and ½ to 1 cup (120-240 mL) water or almond milk to blend

Lunch or Dinner

You can prepare these meals or prep some of the ingredients ahead of time. You can store it for up to three days in the refrigerator or freeze it for later use.

  • Bean chili

  • Healthy soups

    • Mushroom and barley

    • Pumpkin

    • Lentil soup

  • Healthy protein, vegetable, and starch meal

    • Grilled or sautéed fish or chicken breast with roasted, grilled, sautéed, or stir-fried vegetables Quinoa, sweet potato, or squash

  • Vegetable curry or stew with a side of quinoa

  • Vegetable ratatouille with a side of bulgur or barley

  • Build a salad

  • Start with a base: arugula, spinach, and/or kale

    • Pick a protein: tuna, hard-boiled eggs, chickpeas, black beans, edamame, cottage cheese, and/or grated cheese

    • Add some color: sweet potatoes, mixed bell peppers, mushrooms, beets, and/or celery

    • Add some crunch: chopped walnuts, sliced almonds, and/or roasted chickpeas 

    • Top with a dressing or healthy fat: avocado, olives, flaxseed, hemp seed, olive oil with dried herbs, and/or pesto 

Snacks

  • 1 serving Greek yogurt

  • 1 serving of fruit

  • ¼ cup (60 g) of raw unsalted nuts

  • Carrots with 2 tablespoons (20 g) hummus or guacamole

  • ½ ounce (14 g) dark chocolate

  • 1 cup (240 g) cooked edamame 

  • ½ cup (120 g) cottage cheese with 1 serving of fruit

  • 1 cup (240 g) goat milk yogurt with live cultures and 7 almonds

  • 1 baked pear or apple with cinnamon, nutmeg, and walnuts

  • 2 dates with a ¼ cup (60 g) of raw unsalted nuts

Eating Out

Even though restaurant food may be challenging, you can still maintain a healthy diet. It is easier when you plan ahead. You can call the restaurant to ask questions or review their menu online. 

Here are some ideas to consider, depending on the type of cuisine.

Italian

  • Cioppino - a fish or mixed seafood stew combined with fresh tomatoes in a wine sauce Ask if the base contains heavy cream, if so they can make it without the high-fat dairy product

  • Baked or grilled chicken or fish with a side of vegetables. Request that they eliminate butter and cream

  • Whole wheat pasta dish. Ask for olive oil or vegetable (marinara) sauce.  You can request that they add vegetables to the dish

Asian

  • Order sushi with vegetables and salmon or tuna

  • Request brown, instead of white rice

  • Try miso soup or seaweed salad

  • Ask for low-salt soy sauce

  • Avoid tempura and sweet and mayonnaise-based sauces

Indian

  • Many spices used in Indian cooking are anti-inflammatory (e.g. clove, cinnamon, ginger,  turmeric)

  • Try curry or dal (lentil- or garbanzo-based dish)

  • Avoid dishes with added cream

  • Order chicken or fish tandoori - tandoori is an Indian cooking method using a traditional clay oven

  • A great side dish is palak paneer (Indian cottage cheese cooked with spinach and spices)

Fast Food And Quick-Service

  • Burgers, chicken,  and sides

    • Choose grilled instead of fried chicken

    • Skip the cheese, sauce, and bacon

    • Instead of French fries, choose a side salad with low-fat dressing

    • Have the burger without a bun

    • Avoid soda and milkshakes

  • A taco salad with leafy greens, beans, guacamole, salsa, and a lean protein is a good option

  • Chicken or seafood fajitas are a healthy choice since they have grilled, lean protein, and a variety of vegetables

Take-along Snacks

When you’re away from home, take a healthy snack with you. Make sure you check the portion size and ingredient list. Some excellent choices are:

  • Dark chocolate bars (2-3 squares of dark chocolate) *More cacao is better - aim for at least 70%

  • Protein or energy bars (Choose those with only a few ingredients)

  • Snack-size nut butters

  • Snack-size nuts or trail mix 

  • Seeds

  • Popcorn

Think about how you can make your own mixes. You can create combinations of dark chocolate pieces, almonds, sunflower seeds, popcorn, cashews, walnuts, pumpkin seeds, and so on.

Healthy Diet Shopping Suggestions

Use the following suggestions as you prepare your grocery shopping list.

Vegetables

  • Make sure you include a lot of vegetables

  • Some of the best vegetables are green and leafy. Iceberg or head lettuce is not a good choice. Choose arugula, collard, mustard, or turnip greens, leaf lettuce, kale, romaine lettuce, spinach, Swiss chard, or watercress

  • Other green vegetables include artichokes, broccoli, Brussels sprouts, cabbage, green beans, and peas

  • Orange vegetables like carrots, pumpkin, squash, sweet potatoes, and yams are excellent choices

  • Have a salad in mind when you select vegetables! There are endless combinations. A classic one includes leaf lettuce, tomato, carrots, celery, cucumber, peppers, mushrooms, onions, and olives

  • For a change, drink vegetable juice or use vegetable broth for sautéing

Fruit

  • While still in the produce aisle, pick out some in-season fruit 

  • Apples and pears in the fall 

  • Cranberries and oranges in the winter 

  • In the spring and summer, select berries, like blueberries, blackberries, strawberries, and raspberries 

  • Try citrus fruits like oranges, or add lemon or lime slices to flavor your water

  • Be mindful of fruits high in sugar like apricots, bananas, cantaloupes, cherries, figs, grapefruit, grapes, mangos, nectarines, papaya, peaches, pineapple, plums, pomegranates, and watermelon. Enjoy them, but pay attention to portions.

Protein

  • When possible, opt for organic, grass-fed, hormone- and antibiotic-free meats

  • Try pasture-raised or free-range eggs

  • Make sure to include healthy, wild-caught seafood like cod, haddock, halibut, mahi-mahi, red snapper, salmon, sardines, sea bass, trout, and tuna

    • Choose canned fish in water that’s mercury-free

  • Below are good dairy/non-dairy choices

    • Unsweetened almond and coconut milk  

    • Greek or goat’s milk yogurt with live and active cultures

    • Kefir, a fermented dairy product is high in healthy bacteria (probiotics)

Legumes 

  • Legumes provide healthy protein and other nutrients 

  • Consider soup or chili with an assortment of black, kidney, and pinto beans

  • You can include chickpeas, lentils, or peas in a salad 

  • Make or buy hummus as a dip for vegetables

Oils 

  • For cooking and baking, focus on healthy oils like almond, avocado, olive, flaxseed, sesame, and walnut

  • Use ghee (a clarified butter) or butter in small amounts

Nuts and Seeds 

  • Nuts and seeds make great snacks. Make sure you check the serving size

  • Choose raw, unsalted almonds, brazil nuts, cashews, hazelnuts, macadamia nuts, or pecans

  • Add seeds like chia, hemp, sesame, or sunflower to your dishes

  • As an alternative to unsweetened peanut butter, try almond, or walnut butter. You can also add nuts and seeds to almost any dish 

Grains (in moderation)

  • Look for whole-grain - 100% whole grain is best 

  • For breakfast, you can store a supply of unsweetened granola, muesli, or oats 

  • Add a side dish of brown or wild rice, farro, or quinoa to your meal or mixed in your salad

Spices and Flavoring 

  • Buy a few different herbs and spices that help decrease inflammation. Try a new one every few weeks. Have you tried cumin or turmeric? What about sage, rosemary, or thyme?

  • Think about growing some of your favorites right in your kitchen. Basil, dill, oregano, parsley, mint, or cilantro are good choices

  • Bake healthy versions of bars or cookies with cinnamon, clove, ginger, or nutmeg

Condiments, Dips, And Sauces 

  • Stay away from high-fat, high-sugar condiments. Instead use mustard, olive- or avocado oil-based mayonnaise

  • Have guacamole or hummus dips

  • Use olive oil and vinegar (apple cider, balsamic, or red wine) on salads 

  • Have something different like kimchi, fermented vegetables, or sauerkraut (fermented cabbage)

  • Try pesto or tomato sauce with your whole-grain pasta. Make a fresh salsa with tomato, onion, peaches or mango, and cilantro

Beverages 

  • Drink water! Pure, filtered water is best

  • Milk, like almond, coconut, and soy, are good choices. Watch for added sugars

  • Green or herbal teas can be hot or iced

  • Try something like kombucha, a fermented tea. (Read the ingredient list as some are very high in sugar)

Sweeteners

To add sweetness use small amounts of dark chocolate, honey, maple syrup, or stevia.

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