Plant-based diets, pescatarian diets and COVID-19 severity: a population-based case–control study in six countries
Hyunju Kim, Casey M Rebholz, Sheila Hegde, Christine Lafiura, Madhunika Raghavan, John F Lloyd, Susan Cheng, Dr Sara B Seidelmann
BMJ Nutrition, Prevention & Health, doi:10.1136/bmjnph-2021-000272
Background Several studies have hypothesised that dietary habits may play an important role in COVID-19 infection, severity of symptoms, and duration of illness. However, no previous studies have investigated the association between dietary patterns and COVID-19. Methods Healthcare workers (HCWs) from six countries (
Competing interests None declared. Patient consent for publication Not required. Provenance and peer review Not commissioned; externally peer reviewed by Leila Azadbakht, Tehran University of Medical Sciences and David Jenkins, University of Toronto Faculty of Medicine. Data availability statement Data are not publicly available. Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. We compared moderate-to-severe severity (N=87) to very mild to mild severity (N=211). Severity was defined as: 1) Very mild: asymptomatic or nearly asymptomatic, 2) Mild: symptoms [fever <38°C (without treatment), with or without cough, no dyspnea, no gasping, no abnormal imaging findings], 3) Moderate: [fever, respiratory symptoms, and/or imaging findings of pneumonia], 4) Severe: meet any of the following: 1) respiratory distress, respiratory..
References
Ahdea, Jdes, Da Silva-Maia, Nutritional status, diet and viral respiratory infections: perspectives for severe acute respiratory syndrome coronavirus 2, Br J Nutr,
doi:10.1017/S0007114520003311Beck, Nelson, Shi, Selenium deficiency increases the pathology of an influenza virus infection, Faseb J,
doi:10.1096/fj.00-0721fjeBeck, Shi, Morris, Rapid genomic evolution of a non-virulent coxsackievirus B3 in selenium-deficient mice results in selection of identical virulent isolates, Nat Med,
doi:10.1038/nm0595-433Calder, Carr, Gombart, Optimal nutritional status for a well-functioning immune system is an important factor to protect against viral infections, Nutrients,
doi:10.3390/nu12041181Heidemann, Schulze, Franco, Dietary patterns and risk of mortality from cardiovascular disease, cancer, and all causes in a prospective cohort of women, Circulation,
doi:10.1161/CIRCULATIONAHA.108.771881Hemilä, Vitamin E administration may decrease the incidence of pneumonia in elderly males, Clin Interv Aging,
doi:10.2147/CIA.S114515Iddir, Brito, Dingeo, Strengthening the immune system and reducing inflammation and oxidative stress through diet and nutrition: considerations during the COVID-19 crisis, Nutrients,
doi:10.3390/nu12061562Jenkins, Kitts, Giovannucci, Selenium, antioxidants, cardiovascular disease, and all-cause mortality: a systematic review and meta-analysis of randomized controlled trials, Am J Clin Nutr,
doi:10.1093/ajcn/nqaa245Kim, Caulfield, Garcia-Larsen, Plant-based diets and incident CKD and kidney function, Clin J Am Soc Nephrol,
doi:10.2215/CJN.12391018Kim, Hegde, Lafiura, Access to personal protective equipment in exposed healthcare workers and COVID-19 illness, severity, symptoms and duration: a population-based case-control study in six countries, BMJ Glob Health,
doi:10.1136/bmjgh-2020-004611Kim, Hegde, Lafiura, COVID-19 illness in relation to sleep and burnout, BMJ Nutr Prev Health
Kim, Rebholz, Garcia-Larsen, Operational differences in plant-based diet indices affect the ability to detect associations with incident hypertension in middle-aged US adults, J Nutr,
doi:10.1093/jn/nxz275Lemoine, Cm, Brigham, Woo, Omega-3 fatty acid intake and prevalent respiratory symptoms among U.S. adults with COPD, BMC Pulm Med,
doi:10.1186/s12890-019-0852-4Li, Werler, Fruit and vegetable intake and risk of upper respiratory tract infection in pregnant women, Public Health Nutr,
doi:10.1017/S1368980009990590Rodríguez, Ballart, Pastor, Validation of a short questionnaire on frequency of dietary intake: reproducibility and validity
Shah, Wood, Gribben, Risk of hospital admission with coronavirus disease 2019 in healthcare workers and their households: nationwide linkage cohort study, BMJ,
doi:10.1136/bmj.m3582Shearer, Walker, An overview of the biologic effects of omega-6 oxylipins in humans, Prostaglandins Leukot Essent Fatty Acids,
doi:10.1016/j.plefa.2018.06.005Simonnet, Chetboun, Poissy, High prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) requiring invasive mechanical ventilation, Obesity,
doi:10.1002/oby.22831Tavakol, Ghannadi, Tabesh, Relationship between physical activity, healthy lifestyle and COVID-19 disease severity; a cross-sectional study, Z Gesundh Wiss,
doi:10.1007/s10389-020-01468-9Tong, Appleby, Bradbury, Risks of ischaemic heart disease and stroke in meat eaters, fish eaters, and vegetarians over on, BMJ,
doi:10.1136/bmj.l4897Troeger, Blacker, Khalil, Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease study 2016, Lancet Infect Dis,
doi:10.1016/S1473-3099(18)30310-4Worldometer, Coronavirus graphs: worldwide cases and deaths
Yang, Zheng, Gou, Prevalence of comorbidities and its effects in patients infected with SARS-CoV-2: a systematic review and meta-analysis, Int J Infect Dis,
doi:10.1016/j.ijid.2020.03.017Zabetakis, Lordan, Norton, COVID-19: the inflammation link and the role of nutrition in potential mitigation, Nutrients,
doi:10.3390/nu12051466{ 'indexed': {'date-parts': [[2022, 4, 3]], 'date-time': '2022-04-03T05:21:45Z', 'timestamp': 1648963305032},
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'abstract': '<jats:sec><jats:title>Background</jats:title><jats:p>Several studies have hypothesised that '
'dietary habits may play an important role in COVID-19 infection, severity of symptoms, and '
'duration of illness. However, no previous studies have investigated the association between '
'dietary patterns and '
'COVID-19.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>Healthcare '
'workers (HCWs) from six countries (France, Germany, Italy, Spain, UK, USA) with substantial '
'exposure to COVID-19 patients completed a web-based survey from 17 July to 25 September 2020. '
'Participants provided information on demographic characteristics, dietary information, and '
'COVID-19 outcomes. We used multivariable logistic regression models to evaluate the '
'association between self-reported diets and COVID-19 infection, severity, and '
'duration.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>There were 568 '
'COVID-19 cases and 2316 controls. Among the 568 cases, 138 individuals had moderate-to-severe '
'COVID-19 severity whereas 430 individuals had very mild to mild COVID-19 severity. After '
'adjusting for important confounders, participants who reported following ‘plant-based diets’ '
'and ‘plant-based diets or pescatarian diets’ had 73% (OR 0.27, 95% CI 0.10 to 0.81) and 59% '
'(OR 0.41, 95% CI 0.17 to 0.99) lower odds of moderate-to-severe COVID-19 severity, '
'respectively, compared with participants who did not follow these diets. Compared with '
'participants who reported following ‘plant-based diets’, those who reported following ‘low '
'carbohydrate, high protein diets’ had greater odds of moderate-to-severe COVID-19 (OR 3.86, '
'95% CI 1.13 to 13.24). No association was observed between self-reported diets and COVID-19 '
'infection or '
'duration.</jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p>In six '
'countries, plant-based diets or pescatarian diets were associated with lower odds of '
'moderate-to-severe COVID-19. These dietary patterns may be considered for protection against '
'severe COVID-19.</jats:p></jats:sec>',
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'article-title': 'SARS-CoV-2 variants and ending the COVID-19 pandemic',
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'DOI': '10.1002/oby.22831',
'article-title': 'High prevalence of obesity in severe acute respiratory syndrome '
'coronavirus-2 (SARS-CoV-2) requiring invasive mechanical ventilation',
'volume': '28',
'author': 'Simonnet',
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'burnout. BMJ Nutr Prev Health 2021.',
'DOI': '10.1136/bmjnph-2021-000228'},
{ 'key': '2021072714055297000_4.1.257.9',
'unstructured': 'Worldometer . Coronavirus graphs: worldwide cases and deaths. Available: '
'https://www.worldometers.info/coronavirus/worldwide-graphs/ [Accessed 1 '
'Mar 2021].'},
{ 'key': '2021072714055297000_4.1.257.10',
'first-page': '242',
'article-title': '[Validation of a short questionnaire on frequency of dietary intake: '
'reproducibility and validity]',
'volume': '23',
'author': 'Rodríguez',
'year': '2008',
'journal-title': 'Nutr Hosp'},
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'doi-asserted-by': 'crossref',
'first-page': 'E15',
'DOI': '10.1148/radiol.2020200490',
'article-title': 'Coronavirus disease 2019 (COVID-19): a perspective from China',
'volume': '296',
'author': 'Zu',
'year': '2020',
'journal-title': 'Radiology'},
{ 'key': '2021072714055297000_4.1.257.12',
'doi-asserted-by': 'crossref',
'first-page': '842',
'DOI': '10.1093/jn/nxz275',
'article-title': 'Operational differences in plant-based diet indices affect the ability '
'to detect associations with incident hypertension in middle-aged US '
'adults',
'volume': '150',
'author': 'Kim',
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'DOI': '10.1017/S0007114520003311',
'article-title': 'Nutritional status, diet and viral respiratory infections: perspectives '
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'volume': '125',
'author': 'Morais',
'year': '2021',
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'year': '2020',
'journal-title': 'J Glob Antimicrob Resist'},
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'volume': '112',
'author': 'Jenkins',
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'DOI': '10.1186/s12890-019-0852-4',
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'adults with COPD',
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