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Diet for COVID-19: real-time meta analysis of 24 studies

Covid Analysis, June 2023
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0 0.5 1 1.5+ All studies 48% 24 687,838 Improvement, Studies, Patients Relative Risk Mortality 20% 3 360,100 Hospitalization 72% 3 546 Cases 33% 11 402,472 Diet for COVID-19 c19early.org/dt Jun 2023 Favorshealthy diet Favorscontrol after exclusions
•Statistically significant improvements are seen for ICU admission, hospitalization, progression, recovery, and cases. 21 studies from 21 independent teams in 8 different countries show statistically significant improvements in isolation (18 for the most serious outcome).
•Meta analysis using the most serious outcome reported shows 48% [38‑56%] improvement. Results are similar after exclusions.
•Results are robust — in exclusion sensitivity analysis 22 of 24 studies must be excluded to avoid finding statistically significant efficacy in pooled analysis.
0 0.5 1 1.5+ All studies 48% 24 687,838 Improvement, Studies, Patients Relative Risk Mortality 20% 3 360,100 Hospitalization 72% 3 546 Cases 33% 11 402,472 Diet for COVID-19 c19early.org/dt Jun 2023 Favorshealthy diet Favorscontrol after exclusions
•Studies analyze diet quality before infection, and use different definitions of diet quality.
•No treatment, vaccine, or intervention is 100% effective and available. All practical, effective, and safe means should be used based on risk/benefit analysis.
•All data to reproduce this paper and sources are in the appendix. [Rahmati] present another meta analysis for diet, showing significant improvements for hospitalization and cases.
Evolution of COVID-19 clinical evidence Diet p<0.0000000001 Acetaminophen p=0.0000018 2020 2021 2022 2023 Effective Harmful c19early.org June 2023 meta analysis results (pooled effects) 100% 50% 0% -50%
Percentage improvement with higher quality diets (more)
All studies Studies Patients Authors
All studies48% [38‑56%]
****
 24 687,838 323
Mortality20% [-15‑44%] 3 360,100 20
HospitalizationHosp.72% [57‑82%]
****
 3 546 19
Cases33% [23‑42%]
****
 11 402,472 110
Highlights
A healthier diet reduces risk for COVID-19 with very high confidence for hospitalization, cases, and in pooled analysis, low confidence for ICU admission, progression, and recovery, and very low confidence for mortality.
We show traditional outcome specific analyses and combined evidence from all studies.
Real-time updates and corrections, transparent analysis with all results in the same format, consistent protocol for 51 treatments.
A
0 0.25 0.5 0.75 1 1.25 1.5 1.75 2+ Mahto 20% 0.80 [0.49-1.21] IgG+ 23/206 70/483 Improvement, RR [CI] Treatment Control Naushin 40% 0.60 [0.50-0.71] seropositive n/a n/a Kim 72% 0.28 [0.10-0.82] m/s case 41 (n) 527 (n) Merino 41% 0.59 [0.47-0.74] severe case 148,142 (n) 148,143 (n) Moludi 92% 0.08 [0.05-0.19] cases n/a n/a Ahmadi -3% 1.03 [0.77-1.39] death 185/206,286 62/75,264 Nguyen 15% 0.85 [0.75-0.96] symp. case 345/1,054 433/1,082 Yamamoto 66% 0.34 [0.13-0.85] cases 4/20 19/32 Magaña 53% 0.47 [0.22-0.99] death 58 (n) 31 (n) Jagielski 82% 0.18 [0.04-0.65] cases 4/40 9/20 Perez-Araluce 78% 0.22 [0.03-1.77] severe case 1/1,103 10/3,300 Firoozi 65% 0.35 [0.28-0.43] cases case control per unit E-DII change Hou 72% 0.28 [0.04-1.95] severe case 1/22 78/487 Zargarzadeh 77% 0.23 [0.11-0.50] severe case 89 (n) 80 (n) Yue 19% 0.81 [0.69-0.94] cases n/a n/a Zhou 16% 0.84 [0.78-0.91] cases 1,321/10,254 1,935/10,253 Ebrahimzadeh 69% 0.31 [0.14-0.68] severe case n/a n/a Tadbir Vajargah 67% 0.33 [0.16-0.69] severe case 83 (n) 83 (n) Reis 75% 0.25 [0.12-0.52] hosp. 17/380 21/166 Zhao 24% 0.76 [0.53-1.09] death 39,230 (n) 39,231 (n) Mohajeri 25% 0.75 [0.63-0.88] progression 62/105 392/495 Wang 9% 0.91 [0.72-1.14] PASC 124/318 218/480 LONG COVID Zamanian 81% 0.19 [0.07-0.55] hosp. case control Barania Adabi 99% 0.01 [0.00-0.21] ICU 0/125 37/125 Tau​2​ = 0.11, I​2​ = 88.3%, p < 0.0001 Prophylaxis 48% 0.52 [0.44-0.62] 2,087/407,556 3,284/280,282 48% improvement All studies 48% 0.52 [0.44-0.62] 2,087/407,556 3,284/280,282 48% improvement 24 diet COVID-19 studies c19early.org/dt Jun 2023 Tau​2​ = 0.11, I​2​ = 88.3%, p < 0.0001 Effect extraction pre-specified(most serious outcome, see appendix) Favors healthy diet Favors control
0 0.25 0.5 0.75 1 1.25 1.5 1.75 2+ Mahto 20% IgG positive Relative Risk [CI] Naushin 40% seropositive Kim 72% mod./sev. case Merino 41% severe case Moludi 92% case Ahmadi -3% death Nguyen 15% symp. case Yamamoto 66% case Magaña 53% death Jagielski 82% case Perez-Araluce 78% severe case Firoozi 65% case per unit E-DII change Hou 72% severe case Zargarzadeh 77% severe case Yue 19% case Zhou 16% case Ebrahimzadeh 69% severe case Tadbir Vajargah 67% severe case Reis 75% hospitalization Zhao 24% death Mohajeri 25% progression Wang 9% PASC LONG COVID Zamanian 81% hospitalization Barania Adabi 99% ICU admission Tau​2​ = 0.11, I​2​ = 88.3%, p < 0.0001 Prophylaxis 48% 48% improvement All studies 48% 48% improvement 24 diet COVID-19 studies c19early.org/dt Jun 2023 Tau​2​ = 0.11, I​2​ = 88.3%, p < 0.0001 Effect extraction pre-specifiedRotate device for details Favors healthy diet Favors control
B
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Figure 1. A. Random effects meta-analysis. This plot shows pooled effects, see the specific outcome analyses for individual outcomes, and the heterogeneity section for discussion. Effect extraction is pre-specified, using the most serious outcome reported. For details of effect extraction see the appendix. B. Scatter plot showing the most serious outcome in all studies. The diamond shows the results of random effects meta-analysis. C. Results within the context of multiple COVID-19 treatments. 0.9% of 4,015 proposed treatments show efficacy [c19early.org]. D. Timeline of results in diet studies. The marked dates indicate the time when efficacy was known with a statistically significant improvement of ≥10% from ≥3 studies for pooled outcomes and one or more specific outcome. Efficacy based on specific outcomes was delayed by 3.4 months, compared to using pooled outcomes.
Introduction
We analyze all significant studies reporting COVID-19 outcomes as a function of diet quality and providing adjusted results. Search methods, inclusion criteria, effect extraction criteria (more serious outcomes have priority), all individual study data, PRISMA answers, and statistical methods are detailed in Appendix 1. We present random effects meta-analysis results for all studies, individual outcomes, and after exclusions.
Results
Table 1 summarizes the results for all studies, after exclusions, and for specific outcomes. Figure 2, 3, 4, 5, 6, 7, and 8 show forest plots for random effects meta-analysis of all studies with pooled effects, mortality results, ICU admission, hospitalization, progression, recovery, and cases.
Table 1. Random effects meta-analysis for all studies, after exclusions, and for specific outcomes. Results show the percentage improvement with higher quality diets and the 95% confidence interval. **** p<0.0001.
Improvement Studies Patients Authors
All studies48% [38‑56%]
****
24 687,838 323
After exclusions51% [40‑60%]
****
20 686,035 305
Mortality20% [-15‑44%]3 360,100 20
HospitalizationHosp.72% [57‑82%]
****
3 546 19
Cases33% [23‑42%]
****
11 402,472 110
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Figure 2. Random effects meta-analysis for all studies with pooled effects. This plot shows pooled effects, see the specific outcome analyses for individual outcomes, and the heterogeneity section for discussion. Effect extraction is pre-specified, using the most serious outcome reported. For details of effect extraction see the appendix.
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Figure 3. Random effects meta-analysis for mortality results.
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Figure 4. Random effects meta-analysis for ICU admission.
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Figure 5. Random effects meta-analysis for hospitalization.
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Figure 6. Random effects meta-analysis for progression.
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Figure 7. Random effects meta-analysis for recovery.
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Figure 8. Random effects meta-analysis for cases.
Exclusions
To avoid bias in the selection of studies, we analyze all non-retracted studies. Here we show the results after excluding studies with major issues likely to alter results, non-standard studies, and studies where very minimal detail is currently available. Our bias evaluation is based on analysis of each study and identifying when there is a significant chance that limitations will substantially change the outcome of the study. We believe this can be more valuable than checklist-based approaches such as Cochrane GRADE, which may underemphasize serious issues not captured in the checklists, overemphasize issues unlikely to alter outcomes in specific cases (for example, lack of blinding for an objective mortality outcome, or certain specifics of randomization with a very large effect size), or be easily influenced by potential bias. However, they can also be very high quality.
The studies excluded are as below. Figure 9 shows a forest plot for random effects meta-analysis of all studies after exclusions.
[Hou], unadjusted results with no group details. Excluded results: severe case, moderate/severe case.
[Magaña], unadjusted results with no group details.
[Mahto], unadjusted results with no group details.
[Mohajeri], unadjusted results with no group details.
[Yamamoto], unadjusted results with no group details.
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Figure 9. Random effects meta-analysis for all studies after exclusions. This plot shows pooled effects, see the specific outcome analyses for individual outcomes, and the heterogeneity section for discussion. Effect extraction is pre-specified, using the most serious outcome reported. For details of effect extraction see the appendix.
Conclusion
People with healthier diets have reduced risk for COVID-19. Statistically significant improvements are seen for ICU admission, hospitalization, progression, recovery, and cases. 21 studies from 21 independent teams in 8 different countries show statistically significant improvements in isolation (18 for the most serious outcome). Meta analysis using the most serious outcome reported shows 48% [38‑56%] improvement. Results are similar after exclusions. Results are robust — in exclusion sensitivity analysis 22 of 24 studies must be excluded to avoid finding statistically significant efficacy in pooled analysis.
Studies analyze diet quality before infection, and use different definitions of diet quality.
Study Notes
Ahmadi
0 0.5 1 1.5 2+ Mortality -3% Improvement Relative Risk c19early.org/dt Ahmadi et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective 281,550 patients in the United Kingdom No significant difference in mortality Ahmadi et al., Brain, Behavior, and Immunity, doi:10.1016/j.bbi.2021.04.022 Favors healthy diet Favors control
[Ahmadi] Retrospective 468,569 adults in the UK, showing significantly lower COVID-19 mortality with physical activity.
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Barania Adabi
0 0.5 1 1.5 2+ ICU admission, DII, Q1 v... 99% Improvement Relative Risk ICU admission, E-DII, Q1 v... 98% c19early.org/dt Barania Adabi et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective 500 patients in Iran (March - September 2021) Lower ICU admission with healthier diets (p<0.000001) Barania Adabi et al., Frontiers in Nutrition, doi:10.3389/fnut.2023.1075061 Favors healthy diet Favors control
[Barania Adabi] Retrospective 500 COVID-19 patients, showing dietary inflammatory index (DII) and energy-adjusted dietary inflammatory index (E-DII) associated with COVID-19 severity.
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Ebrahimzadeh
0 0.5 1 1.5 2+ Severe case 69% Improvement Relative Risk Hospitalization 56% Recovery 68% c19early.org/dt Ebrahimzadeh et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective study in Iran (June - September 2021) Lower severe cases (p=0.0037) and improved recovery (p=0.0032) Ebrahimzadeh et al., Frontiers in Nutrition, doi:10.3389/fnut.2022.929384 Favors healthy diet Favors control
[Ebrahimzadeh] Retrospective 250 recovered COVID-19 patients, showing lower risk of severe cases and shorter recovery and hospitalization times with a healthy diet.

Notably, all individual symptoms show lower incidence with a healthy diet with the exception of fever and chills. Fever and chills help the immune system fight infections (shivering helps to raise the body temperature).
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Firoozi
0 0.5 1 1.5 2+ Case 65% Improvement Relative Risk c19early.org/dt Firoozi et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective study in Iran (March - June 2020) Fewer cases with healthier diets (p<0.000001) Firoozi et al., Int. J. Clinical Practice, doi:10.1155/2022/5452488 Favors healthy diet Favors control
[Firoozi] Retrospective 133 COVID-19 patients and 322 controls, showing higher risk of COVID-19 for diets that have a higher inflammatory index (E-DII).
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Hou
0 0.5 1 1.5 2+ Critical case 72% Improvement Relative Risk Moderate to critical case 11% Critical case, age >65 74% Moderate to critical case.. 35% c19early.org/dt Hou et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective 509 patients in Taiwan (May - August 2021) Lower severe cases with healthier diets (not stat. sig., p=0.23) Hou et al., Frontiers in Nutrition, doi:10.3389/fnut.2022.837458 Favors healthy diet Favors control
[Hou] Retrospective 509 COVID-19 patients in Taiwan, showing higher risk of critical COVID-19 cases with non-vegetarian diets.
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Jagielski
0 0.5 1 1.5 2+ Case 82% Improvement Relative Risk c19early.org/dt Jagielski et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective 95 patients in Poland Fewer cases with healthier diets (p=0.005) Jagielski et al., Nutrients, doi:10.3390/nu14020350 Favors healthy diet Favors control
[Jagielski] Retrospective 95 people in Poland, showing significantly lower risk of COVID-19 with higher consumption of fruits, vegetables, and nuts. Diets with higher consumption of fruits, vegetables, and nuts had a significantly lower dietary inflammatory index.
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Kim
0 0.5 1 1.5 2+ Moderate/severe case 72% Improvement Relative Risk Moderate/severe case (b) 59% Case 19% Case (b) 23% c19early.org/dt Kim et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective 568 patients in multiple countries (Jul - Sep 2020) Fewer moderate/severe cases with healthier diets (p=0.02) Kim et al., BMJ Nutrition, Prevention & Health, doi:10.1136/bmjnph-2021-000272 Favors healthy diet Favors control
[Kim] Retrospective healthcare workers in six countries with exposure to COVID-19 patients, showing lower risk of moderate/severe COVID-19 with plant-based diets.
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Magaña
0 0.5 1 1.5 2+ Mortality 53% Improvement Relative Risk c19early.org/dt Magaña et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective 89 patients in Spain Lower mortality with healthier diets (p=0.049) Magaña et al., Clinical Nutrition ESPEN, doi:10.1016/j.clnesp.2021.09.606 Favors healthy diet Favors control
[Magaña] Retrospective 89 COVID-19 patients in Spain, showing lower mortality with adherence to the Mediterranean diet.
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Mahto
0 0.5 1 1.5 2+ IgG positive 20% unadjusted Improvement Relative Risk c19early.org/dt Mahto et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective 689 patients in India Lower IgG positivity with healthier diets (not stat. sig., p=0.32) Mahto et al., American J. Blood Research, 11:1 Favors healthy diet Favors control
[Mahto] Retrospective 689 healthcare workers in India, showing non-statistically significant lower risk of IgG positivity with a vegetarian diet in unadjusted results.
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Merino
0 0.5 1 1.5 2+ Severe case 41% Improvement Relative Risk Case 18% Case (b) 9% c19early.org/dt Merino et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective 296,285 patients in multiple countries (Mar - Dec 2020) Lower severe cases (p<0.0001) and fewer cases (p<0.0001) Merino et al., Gut, doi:10.1136/gutjnl-2021-325353 Favors healthy diet Favors control
[Merino] Retrospective 592,571 participants in the UK and USA with 31,815 COVID-19 cases, showing lower risk or COVID-19 cases and severity for higher healthful plant-based diet scores. Notably, the assocation was less evident with higher levels of physical activity.
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Mohajeri
0 0.5 1 1.5 2+ Progression, dyspnea 25% Improvement Relative Risk Progression, fever 51% Progression, taste/smell 70% Progression, fatigue -10% Progression, cough 53% Progression, diarrhea 26% c19early.org/dt Mohajeri et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective 600 patients in Iran Lower progression with healthier diets (p=0.00003) Mohajeri et al., Medicina, doi:10.3390/medicina59020227 Favors healthy diet Favors control
[Mohajeri] Retrospective 600 COVID-19 patients in Iran with moderate/severe CT scans, showing lower prevalence of dyspnea, fever, taste/smell abnormalities, and cough with high adherence to the Mediterranean diet in unadjusted results.
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Moludi
0 0.5 1 1.5 2+ Case 92% Improvement Relative Risk c19early.org/dt Moludi et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective study in Iran (June - July 2020) Fewer cases with healthier diets (p<0.000001) Moludi et al., British J. Nutrition, doi:10.1017/S0007114521003214 Favors healthy diet Favors control
[Moludi] Retrospective 60 COVID-19 hospitalized patients and 60 controls in Iran, showing pro-inflammatory diets associated with COVID-19 cases and severity. IR.KUMS.REC.1399·444, IR.TBZMED.REC.1399·225.
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Naushin
0 0.5 1 1.5 2+ Seropositive 40% Improvement Relative Risk c19early.org/dt Naushin et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective study in India Lower seropositivity with healthier diets (p<0.000001) Naushin et al., eLife, doi:10.7554/eLife.66537 Favors healthy diet Favors control
[Naushin] Retrospective 10,427 volunteers in India, 1,058 anti-nucleocapsid antibody positive, showing lower risk of seropositivity with a vegetarian diet.
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Nguyen
0 0.5 1 1.5 2+ Symptomatic case 15% Improvement Relative Risk Symptomatic case (b) 42% c19early.org/dt Nguyen et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective 2,136 patients in Vietnam (February - March 2020) Fewer symptomatic cases with healthier diets (p=0.006) Nguyen et al., Nutrients, doi:10.3390/nu13093258 Favors healthy diet Favors control
[Nguyen] Analysis of 3,947 participants in Vietnam, showing significantly lower risk of COVID-19-like symptoms with physical activity and with a healthy diet. The combination of being physically active and eating healthy reduced risk further compared to either alone. The analyzed period was Feb 14 to Mar 2, 2020, which may have been before testing was widely available.
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Perez-Araluce
0 0.5 1 1.5 2+ Severe case 78% Improvement Relative Risk Symptomatic case 15% Case 20% c19early.org/dt Perez-Araluce et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective 4,403 patients in Spain (March - December 2020) Lower severe cases (p=0.15) and fewer symptomatic cases (p=0.31), not stat. sig. Perez-Araluce et al., Frontiers in Nutrition, doi:10.3389/fnut.2021.805533 Favors healthy diet Favors control
[Perez-Araluce] Retrospective 5,194 participants in Spain with 382 COVID-19 cases, showing lower risk of COVID-19 with high adherence to a Mediterranean diet, with statistical significance only when excluding healthcare professionals.
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Reis
0 0.5 1 1.5 2+ Hospitalization 75% Improvement Relative Risk c19early.org/dt Reis et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective 546 patients in the USA (December 2020 - February 2021) Lower hospitalization with healthier diets (p=0.00025) Reis et al., American J. Lifestyle Medicine, doi:10.1177/15598276221135541 Favors healthy diet Favors control
[Reis] Retrospective 546 COVID+ patients in the USA, showing lower risk of hospitalization with higher consumption of vegetables.
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Tadbir Vajargah
0 0.5 1 1.5 2+ Severe case, vegetables 67% Improvement Relative Risk Severe case, fruit 72% Severe case, fiber 75% c19early.org/dt Tadbir Vajargah et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Prospective study of 166 patients in Iran (June - September 2021) Lower severe cases with healthier diets (p=0.003) Tadbir Vajargah et al., Frontiers in Nutrition, doi:10.3389/fnut.2022.934568 Favors healthy diet Favors control
[Tadbir Vajargah] Retrospective 250 hospitalized patients in Iran, showing higher consumption of fruits, vegetables, and fiber associated with lower COVID-19 severity.
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Wang
0 0.5 1 1.5 2+ PASC, diet 9% Improvement Relative Risk PASC, healthy lifestyle 49% Hospitalization, healthy lif.. 78% c19early.org/dt Wang et al. Diet for COVID-19 LONG COVID Does a healthy diet reduce the risk of Long COVID (PASC)? Prospective study of 798 patients in the USA (Apr 2020 - Nov 2021) No significant difference in PASC Wang et al., JAMA Internal Medicine, doi:10.1001/jamainternmed.2022.6555 Favors healthy diet Favors control
[Wang] Prospective analysis of 32,249 women from the Nurses’ Health Study II in the USA, showing lower risk of PASC with a healthy lifestyle, and in a dose-dependent manner. Participants with 5 or 6 healthy lifestyle factors had significantly lower COVID-19 hospitalization and PASC. BMI and sleep were independently associated with risk of PASC.
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Yamamoto
0 0.5 1 1.5 2+ Case 66% Improvement Relative Risk c19early.org/dt Yamamoto et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective 52 patients in the USA Fewer cases with healthier diets (p=0.0092) Yamamoto et al., Scientific Reports, doi:10.1038/s41598-021-04350-0 Favors healthy diet Favors control
[Yamamoto] Retrospective 84 flight attendants, 52 reporting COVID-19 status and diet quality, showing higher risk of COVID-19 with lower self-reported diet quality.
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Yue
0 0.5 1 1.5 2+ Case, AHEI 19% Improvement Relative Risk Case, AMED 21% Case, EDIH 29% Case, EDIP 12% c19early.org/dt Yue et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective study in multiple countries Fewer cases with healthier diets (p=0.0076) Yue et al., The American J. Clinical Nutrition, doi:10.1093/ajcn/nqac219 Favors healthy diet Favors control
[Yue] Analysis of 42,935 participants showing lower risk of COVID-19 with healthier diets. Risk of severe cases was also lower with healthier diets, while not reaching statistical significance. Severity results are only provided with diet indices as a continuous variable.
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Zamanian
0 0.5 1 1.5 2+ Hospitalization 81% Improvement Relative Risk c19early.org/dt Zamanian et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective 141 patients in Iran Lower hospitalization with healthier diets (p=0.0016) Zamanian et al., Clinical Nutrition Open Science, doi:10.1016/j.nutos.2023.02.001 Favors healthy diet Favors control
[Zamanian] Case control study with 53 inpatients and 88 outpatients in Iran, showing lower risk of hospitalization with increased adherence to the DASH (Dietary Approach to Stop Hypertension) diet. Increased intake of fruits, vegetables and low-fat dairy products, and lower intake of sodium and processed/red meat were significantly associated with reduced risk of hospitalization due to COVID-19.
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Zargarzadeh
0 0.5 1 1.5 2+ Severe case 77% Improvement Relative Risk c19early.org/dt Zargarzadeh et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective 169 patients in Iran (June - September 2021) Lower severe cases with healthier diets (p=0.00016) Zargarzadeh et al., Frontiers in Medicine, doi:10.3389/fmed.2022.911273 Favors healthy diet Favors control
[Zargarzadeh] Retrospective 250 COVID-19 patients in Iran, showing lower risk of severe disease with greater adherence to a Mediterranean diet.
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Zhao
0 0.5 1 1.5 2+ Mortality, E-DII 24% Improvement Relative Risk Mortality, DII 30% Severe case, E-DII 28% Severe case, DII 29% Case, E-DII 15% Case, DII 9% c19early.org/dt Zhao et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Retrospective 196,154 patients in the United Kingdom (Jan 2020 - Mar 2021) Lower severe cases (p=0.00034) and fewer cases (p<0.0001) Zhao et al., SSRN Electronic J., doi:10.2139/ssrn.4300209 Favors healthy diet Favors control
[Zhao] UK Biobank retrospective 196,154 participants with 11,288 COVID-19 cases, showing lower COVID-19 mortality, severity, and incidence for lower dietary inflammatory scores.
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Zhou
0 0.5 1 1.5 2+ Case 16% Improvement Relative Risk c19early.org/dt Zhou et al. Diet for COVID-19 Prophylaxis Is a healthy diet beneficial for COVID-19? Prospective study of 20,507 patients in the United Kingdom Fewer cases with healthier diets (p=0.000011) Zhou et al., European J. Nutrition, doi:10.1007/s00394-022-02982-0 Favors healthy diet Favors control
[Zhou] Prospective study of 41,012 UK Biobank participants, showing higher risk of COVID-19 cases with ultra-processed food consumption.
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Appendix 1. Methods and Data
We performed ongoing searches of PubMed, medRxiv, ClinicalTrials.gov, The Cochrane Library, Google Scholar, Collabovid, Research Square, ScienceDirect, Oxford University Press, the reference lists of other studies and meta-analyses, and submissions to the site c19early.org. Search terms were diet AND COVID-19. Automated searches are performed every few hours with notification of new matches. All studies regarding the use of diet for COVID-19 that report a comparison with a control group are included in the main analysis. Sensitivity analysis is performed, excluding studies with major issues, epidemiological studies, and studies with minimal available information. This is a living analysis and is updated regularly.
We extracted effect sizes and associated data from all studies. If studies report multiple kinds of effects then the most serious outcome is used in pooled analysis, while other outcomes are included in the outcome specific analyses. For example, if effects for mortality and cases are both reported, the effect for mortality is used, this may be different to the effect that a study focused on. If symptomatic results are reported at multiple times, we used the latest time, for example if mortality results are provided at 14 days and 28 days, the results at 28 days are used. Mortality alone is preferred over combined outcomes. Outcomes with zero events in both arms were not used (the next most serious outcome is used — no studies were excluded). For example, in low-risk populations with no mortality, a reduction in mortality with treatment is not possible, however a reduction in hospitalization, for example, is still valuable. Clinical outcome is considered more important than PCR testing status. When basically all patients recover in both treatment and control groups, preference for viral clearance and recovery is given to results mid-recovery where available (after most or all patients have recovered there is no room for an effective treatment to do better). If only individual symptom data is available, the most serious symptom has priority, for example difficulty breathing or low SpO2 is more important than cough. When results provide an odds ratio, we computed the relative risk when possible, or converted to a relative risk according to [Zhang]. Reported confidence intervals and p-values were used when available, using adjusted values when provided. If multiple types of adjustments are reported including propensity score matching (PSM), the PSM results are used. Adjusted primary outcome results have preference over unadjusted results for a more serious outcome when the adjustments significantly alter results. When needed, conversion between reported p-values and confidence intervals followed [Altman, Altman (B)], and Fisher's exact test was used to calculate p-values for event data. If continuity correction for zero values is required, we use the reciprocal of the opposite arm with the sum of the correction factors equal to 1 [Sweeting]. Results are expressed with RR < 1.0 favoring treatment, and using the risk of a negative outcome when applicable (for example, the risk of death rather than the risk of survival). If studies only report relative continuous values such as relative times, the ratio of the time for the treatment group versus the time for the control group is used. Calculations are done in Python (3.11.3) with scipy (1.10.1), pythonmeta (1.26), numpy (1.24.3), statsmodels (0.14.0), and plotly (5.14.1).
Forest plots are computed using PythonMeta [Deng] with the DerSimonian and Laird random effects model (the fixed effect assumption is not plausible in this case) and inverse variance weighting. Mixed-effects meta-regression results are computed with R (4.1.2) using the metafor (3.0-2) and rms (6.2-0) packages, and using the most serious sufficiently powered outcome.
We received no funding, this research is done in our spare time. We have no affiliations with any pharmaceutical companies or political parties.
We have classified studies as early treatment if most patients are not already at a severe stage at the time of treatment (for example based on oxygen status or lung involvement), and treatment started within 5 days of the onset of symptoms. If studies contain a mix of early treatment and late treatment patients, we consider the treatment time of patients contributing most to the events (for example, consider a study where most patients are treated early but late treatment patients are included, and all mortality events were observed with late treatment patients). We note that a shorter time may be preferable. Antivirals are typically only considered effective when used within a shorter timeframe, for example 0-36 or 0-48 hours for oseltamivir, with longer delays not being effective [McLean, Treanor].
A summary of study results is below. Please submit updates and corrections at the bottom of this page.
A summary of study results is below. Please submit updates and corrections at https://c19early.org/dtmeta.html.
Prophylaxis
Effect extraction follows pre-specified rules as detailed above and gives priority to more serious outcomes. For pooled analyses, the first (most serious) outcome is used, which may differ from the effect a paper focuses on. Other outcomes are used in outcome specific analyses.
[Ahmadi], 8/31/2021, retrospective, United Kingdom, peer-reviewed, 5 authors.
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 risk of death, 3.0% higher, RR 1.03, p = 0.85, adjusted per study, good vs. poor, model 2, multivariable.
[Barania Adabi], 3/31/2023, retrospective, Iran, peer-reviewed, survey, mean age 40.3, 5 authors, study period March 2021 - September 2021.
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 risk of ICU admission, 98.7% lower, RR 0.01, p < 0.001, higher quality diet 0 of 125 (0.0%), lower quality diet 37 of 125 (29.6%), NNT 3.4, relative risk is not 0 because of continuity correction due to zero events (with reciprocal of the contrasting arm), DII, quartile I vs. quartile IV.
risk of ICU admission, 98.1% lower, RR 0.02, p < 0.001, higher quality diet 0 of 125 (0.0%), lower quality diet 26 of 125 (20.8%), NNT 4.8, relative risk is not 0 because of continuity correction due to zero events (with reciprocal of the contrasting arm), E-DII, quartile I vs. quartile IV.
[Ebrahimzadeh], 8/19/2022, retrospective, Iran, peer-reviewed, survey, 3 authors, study period June 2021 - September 2021.
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 risk of severe case, 69.0% lower, OR 0.31, p = 0.004, healthy diet, T3 vs. T1, model 3, RR approximated with OR.
risk of hospitalization, 56.0% lower, OR 0.44, p = 0.07, hospitalization time, healthy diet, T3 vs. T1, model 3, RR approximated with OR.
risk of no recovery, 68.0% lower, OR 0.32, p = 0.003, recovery duration, healthy diet, T3 vs. T1, model 3, RR approximated with OR.
[Firoozi], 3/29/2022, retrospective, Iran, peer-reviewed, survey, 8 authors, study period March 2020 - June 2020.
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 risk of case, 65.0% lower, OR 0.35, p < 0.001, adjusted per study, inverted to make OR<1 favor higher quality diet, case control OR, multivariable, per unit E-DII change.
[Hou], 4/29/2022, retrospective, Taiwan, peer-reviewed, survey, 3 authors, study period May 2021 - August 2021.
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 risk of critical case, 71.6% lower, RR 0.28, p = 0.23, higher quality diet 1 of 22 (4.5%), lower quality diet 78 of 487 (16.0%), NNT 8.7, excluded in exclusion analyses: unadjusted results with no group details.
risk of moderate to critical case, 10.8% lower, RR 0.89, p = 0.66, higher quality diet 11 of 22 (50.0%), lower quality diet 273 of 487 (56.1%), NNT 17, excluded in exclusion analyses: unadjusted results with no group details.
risk of critical case, 73.6% lower, RR 0.26, p = 0.005, higher quality diet 0 of 9 (0.0%), lower quality diet 47 of 127 (37.0%), NNT 2.7, adjusted per study, inverted to make RR<1 favor higher quality diet, odds ratio converted to relative risk, multivariable, age >65.
risk of moderate to critical case, 34.7% lower, RR 0.65, p = 0.04, higher quality diet 5 of 9 (55.6%), lower quality diet 108 of 127 (85.0%), NNT 3.4, age >65, excluded in exclusion analyses: unadjusted results with no group details.
[Jagielski], 1/14/2022, retrospective, Poland, peer-reviewed, 7 authors.
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 risk of case, 81.5% lower, RR 0.18, p = 0.005, higher quality diet 4 of 40 (10.0%), lower quality diet 9 of 20 (45.0%), NNT 2.9, adjusted per study, inverted to make RR<1 favor higher quality diet, odds ratio converted to relative risk, model 2, FV ≥ 500g and nuts ≥ 10g vs. FV < 500g and nuts < 10g, multivariable.
[Kim], 6/7/2021, retrospective, multiple countries, peer-reviewed, survey, 8 authors, study period 17 July, 2020 - 25 September, 2020.
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 risk of moderate/severe case, 72.0% lower, OR 0.28, p = 0.02, higher quality diet 41, lower quality diet 527, adjusted per study, plant-based diets, multivariable, RR approximated with OR.
risk of moderate/severe case, 59.0% lower, OR 0.41, p = 0.05, higher quality diet 46, lower quality diet 522, adjusted per study, plant-based or pescatarian diets, multivariable, RR approximated with OR.
risk of case, 19.0% lower, OR 0.81, p = 0.24, higher quality diet 41, lower quality diet 527, adjusted per study, plant-based diets, multivariable, RR approximated with OR.
risk of case, 23.0% lower, OR 0.77, p = 0.14, higher quality diet 46, lower quality diet 522, adjusted per study, plant-based or pescatarian diets, multivariable, RR approximated with OR.
[Magaña], 12/31/2021, retrospective, Spain, peer-reviewed, 6 authors, excluded in exclusion analyses: unadjusted results with no group details.
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 risk of death, 53.0% lower, HR 0.47, p = 0.049, higher quality diet 58, lower quality diet 31.
[Mahto], 2/15/2021, retrospective, India, peer-reviewed, 6 authors, excluded in exclusion analyses: unadjusted results with no group details.
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 risk of IgG positive, 20.4% lower, RR 0.80, p = 0.32, higher quality diet 23 of 206 (11.2%), lower quality diet 70 of 483 (14.5%), NNT 30, unadjusted, inverted to make RR<1 favor higher quality diet, odds ratio converted to relative risk.
[Merino], 6/25/2021, retrospective, multiple countries, peer-reviewed, survey, 30 authors, study period 24 March, 2020 - 2 December, 2020.
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 risk of severe case, 41.0% lower, HR 0.59, p < 0.001, higher quality diet 148,142, lower quality diet 148,143, adjusted per study, model 3, high vs. low hPDI, multivariable, Cox proportional hazards.
risk of case, 18.0% lower, HR 0.82, p < 0.001, higher quality diet 148,142, lower quality diet 148,143, adjusted per study, model 3, high vs. low hPDI, PCR+, multivariable, Cox proportional hazards.
risk of case, 9.0% lower, HR 0.91, p < 0.001, higher quality diet 148,142, lower quality diet 148,143, adjusted per study, model 3, high vs. low hPDI, multivariable, Cox proportional hazards.
[Mohajeri], 1/26/2023, retrospective, Iran, peer-reviewed, survey, 3 authors, excluded in exclusion analyses: unadjusted results with no group details.
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 risk of progression, 25.4% lower, RR 0.75, p < 0.001, higher quality diet 62 of 105 (59.0%), lower quality diet 392 of 495 (79.2%), NNT 5.0, dyspnea.
risk of progression, 51.1% lower, RR 0.49, p < 0.001, higher quality diet 50 of 105 (47.6%), lower quality diet 482 of 495 (97.4%), NNT 2.0, fever.
risk of progression, 70.3% lower, RR 0.30, p < 0.001, higher quality diet 23 of 105 (21.9%), lower quality diet 365 of 495 (73.7%), NNT 1.9, taste/smell.
risk of progression, 9.7% higher, RR 1.10, p = 0.03, higher quality diet 98 of 105 (93.3%), lower quality diet 421 of 495 (85.1%), fatigue.
risk of progression, 52.9% lower, RR 0.47, p < 0.001, higher quality diet 38 of 105 (36.2%), lower quality diet 380 of 495 (76.8%), NNT 2.5, cough.
risk of progression, 25.9% lower, RR 0.74, p = 0.007, higher quality diet 44 of 105 (41.9%), lower quality diet 280 of 495 (56.6%), NNT 6.8, diarrhea.
[Moludi], 8/23/2021, retrospective, Iran, peer-reviewed, 7 authors, study period June 2020 - July 2020.
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 risk of case, 91.6% lower, OR 0.08, p < 0.001, inverted to make OR<1 favor higher quality diet, case control OR, model 3, E-DII tertile 1 vs. tertile 3.
[Naushin], 4/20/2021, retrospective, India, peer-reviewed, survey, 136 authors.
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 risk of seropositive, 40.1% lower, OR 0.60, p < 0.001, inverted to make OR<1 favor higher quality diet, RR approximated with OR.
[Nguyen], 9/18/2021, retrospective, Vietnam, peer-reviewed, survey, 17 authors, study period 14 February, 2020 - 2 March, 2020.
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 risk of symptomatic case, 15.2% lower, RR 0.85, p = 0.006, higher quality diet 345 of 1,054 (32.7%), lower quality diet 433 of 1,082 (40.0%), NNT 14, adjusted per study, odds ratio converted to relative risk, high vs. low HES, COVID-19-like symptoms, multivariable.
[Perez-Araluce], 1/24/2022, retrospective, Spain, peer-reviewed, survey, 4 authors, study period March 2020 - December 2020.
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 risk of severe case, 77.9% lower, RR 0.22, p = 0.15, higher quality diet 1 of 1,103 (0.1%), lower quality diet 10 of 3,300 (0.3%), NNT 471, odds ratio converted to relative risk, high vs. low adherence.
risk of symptomatic case, 15.1% lower, RR 0.85, p = 0.31, higher quality diet 52 of 1,103 (4.7%), lower quality diet 214 of 3,300 (6.5%), odds ratio converted to relative risk, high vs. low adherence.
risk of case, 19.7% lower, RR 0.80, p = 0.14, higher quality diet 58 of 1,103 (5.3%), lower quality diet 248 of 3,300 (7.5%), odds ratio converted to relative risk, high vs. low adherence.
[Reis], 10/24/2022, retrospective, USA, peer-reviewed, survey, 6 authors, study period December 2020 - February 2021.
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 risk of hospitalization, 74.8% lower, RR 0.25, p < 0.001, higher quality diet 17 of 380 (4.5%), lower quality diet 21 of 166 (12.7%), adjusted per study, inverted to make RR<1 favor higher quality diet, odds ratio converted to relative risk, 3+ vegetable servings/day vs. <3, multivariable.
[Tadbir Vajargah], 9/29/2022, prospective, Iran, peer-reviewed, survey, mean age 44.2, 11 authors, study period June 2021 - September 2021.
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 risk of severe case, 67.0% lower, OR 0.33, p = 0.003, higher quality diet 83, lower quality diet 83, vegetables, highest vs. lowest tertile, RR approximated with OR.
risk of severe case, 72.0% lower, OR 0.28, p < 0.001, higher quality diet 83, lower quality diet 83, fruit, highest vs. lowest tertile, RR approximated with OR.
risk of severe case, 75.0% lower, OR 0.25, p < 0.001, higher quality diet 83, lower quality diet 83, fiber, highest vs. lowest tertile, RR approximated with OR.
[Wang], 2/6/2023, prospective, USA, peer-reviewed, survey, mean age 64.7, 8 authors, study period April 2020 - November 2021.
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 risk of PASC, 9.0% lower, RR 0.91, p = 0.43, higher quality diet 124 of 318 (39.0%), lower quality diet 218 of 480 (45.4%), NNT 16, adjusted per study, Q5 vs. Q1, multivariable, model 2.
risk of PASC, 49.0% lower, RR 0.51, p = 0.002, higher quality diet 188, lower quality diet 66, 5 or 6 healthy lifestyle factors vs. 0.
[Yamamoto], 12/30/2021, retrospective, USA, peer-reviewed, survey, mean age 35.0, 3 authors, excluded in exclusion analyses: unadjusted results with no group details.
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 risk of case, 66.3% lower, RR 0.34, p = 0.009, higher quality diet 4 of 20 (20.0%), lower quality diet 19 of 32 (59.4%), NNT 2.5, good, very good, excellent vs. fair, poor.
[Yue], 8/9/2022, retrospective, multiple countries, peer-reviewed, survey, 11 authors.
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 risk of case, 19.0% lower, OR 0.81, p = 0.008, Q4 vs. Q1, model 3 + IPW, AHEI, RR approximated with OR.
risk of case, 21.0% lower, OR 0.79, p = 0.006, Q4 vs. Q1, model 3 + IPW, AMED, RR approximated with OR.
risk of case, 28.6% lower, OR 0.71, p < 0.001, inverted to make OR<1 favor higher quality diet, Q1 vs. Q4, model 3 + IPW, EDIH, RR approximated with OR.
risk of case, 11.5% lower, OR 0.88, p = 0.10, inverted to make OR<1 favor higher quality diet, Q1 vs. Q4, model 3 + IPW, EDIP, RR approximated with OR.
[Zamanian], 3/3/2023, retrospective, Iran, peer-reviewed, mean age 46.2, 10 authors.
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 risk of hospitalization, 81.0% lower, OR 0.19, p = 0.002, higher quality diet 41, lower quality diet 53, adjusted per study, case control OR, DASH ≥27 vs. ≤22, multivariable, model 3.
[Zargarzadeh], 7/19/2022, retrospective, Iran, peer-reviewed, mean age 44.1, 11 authors, study period June 2021 - September 2021.
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 risk of severe case, 77.0% lower, OR 0.23, p < 0.001, higher quality diet 89, lower quality diet 80, adjusted per study, top tertile vs. lowest tertile, MD score, model 3, multivariable, RR approximated with OR.
[Zhao], 12/14/2022, retrospective, United Kingdom, peer-reviewed, survey, 9 authors, study period January 2020 - March 2021.
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 risk of death, 24.2% lower, RR 0.76, p = 0.13, higher quality diet 39,230, lower quality diet 39,231, adjusted per study, inverted to make RR<1 favor higher quality diet, E-DII, quintile 1 vs. quintile 5, multivariable, model 4.
risk of death, 30.1% lower, RR 0.70, p = 0.04, higher quality diet 39,230, lower quality diet 39,231, adjusted per study, inverted to make RR<1 favor higher quality diet, DII, quintile 1 vs. quintile 5, multivariable, model 4.
risk of severe case, 28.1% lower, RR 0.72, p < 0.001, higher quality diet 39,230, lower quality diet 39,231, adjusted per study, inverted to make RR<1 favor higher quality diet, E-DII, quintile 1 vs. quintile 5, multivariable, model 4.
risk of severe case, 28.6% lower, RR 0.71, p < 0.001, higher quality diet 39,230, lower quality diet 39,231, adjusted per study, inverted to make RR<1 favor higher quality diet, DII, quintile 1 vs. quintile 5, multivariable, model 4.
risk of case, 14.5% lower, RR 0.85, p < 0.001, higher quality diet 39,230, lower quality diet 39,231, adjusted per study, inverted to make RR<1 favor higher quality diet, E-DII, quintile 1 vs. quintile 5, multivariable, model 4.
risk of case, 9.1% lower, RR 0.91, p = 0.002, higher quality diet 39,230, lower quality diet 39,231, adjusted per study, inverted to make RR<1 favor higher quality diet, DII, quintile 1 vs. quintile 5, multivariable, model 4.
[Zhou], 8/16/2022, prospective, United Kingdom, peer-reviewed, 6 authors.
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 risk of case, 15.7% lower, RR 0.84, p < 0.001, higher quality diet 1,321 of 10,254 (12.9%), lower quality diet 1,935 of 10,253 (18.9%), inverted to make RR<1 favor higher quality diet, odds ratio converted to relative risk, Q4 vs. Q1, model 3 (before healthy diet score adjustment).
Supplementary Data
Supplementary Data
References
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