Nutritional and lifestyle changes required for minimizing the recovery period in home quarantined COVID‐19 patients of Punjab, Pakistan

Abstract The COVID‐19 pandemic has introduced a new battle in human history for a safe and fearless life. Therefore, this cross‐sectional survey was conducted (Punjab, Pakistan) on healthy recovered, home quarantined COVID‐19 patients to draw conclusive health support guidelines in the fight against this pandemic. COVID‐19 recovered patients (n = 80) of age ≥14 years were randomly selected during the period November 2020 to February 2021. A nutrition and lifestyle changes questionnaire, containing ten sections and seventy questions, was completed through the telephone/WhatsApp. Data were transferred into an Excel spreadsheet and statistically analyzed by applying chi‐square, correlation, and a t test of independent values using SPSS‐16 software. The patients had an age range of 14 to 80 years, of which 52 (65%) were male and 28 (35%) were female, and 32 (40%) had a normal BMI. The patients had a peak COVID‐19 recovery period of 2 weeks, and a mean recovery period of 2.8 ± 1.4 weeks. Certain variables, including gender (males), age (>40 years), sleep (≤5 hr), less/no physical activity, obesity, diabetes mellitus, and autoimmune diseases, were significantly associated with delayed recovery. Poor nutritional outcomes, including lower intakes of water, legumes, nuts, meat, and milk/yogurt; and higher consumption of fast/fried/junk/spicy foods and cold water/drinks, were also significantly associated with a longer recovery period. The results were similar for not taking daily doses of multivitamins, and vitamins C, D, E, and zinc. This study identified that staying physically active, maintaining sensible body weight, having a sleep of 7 hr, consuming more foods of plant origin especially plant‐based proteins from nuts and legumes, taking supplemental doses of multivitamins, vitamin D, E, and zinc, along with drinking ≥2 L of water daily can provide a significant role in early and safe recovery from COVID‐19.


| INTRODUC TI ON
The World Health Organization (WHO) was notified about abundantly rising unknown pneumonia cases in the city of Wuhan, China, during December 2019 that were later announced like a novel coronavirus . This outbreak brought large-scale human threat and was defined as a pandemic by the WHO (Messina et al., 2020;Naja & Hamadeh, 2020). The threats associated with this coronavirus are possibly due to the uncontrolled production of pro-inflammatory cytokines. It is similar to other highly virulent respiratory viruses, which result in significant numbers of critical care patients in intensive care units (9%-11%) and a significant mortality rate (5%-7%).
Hence, appropriate steps to control and treat this viral infection had to be taken (Messina et al., 2020).
The current COVID-19 pandemic has directed the focus of nutrition research from noncommunicable diseases toward communicable disease. The public, researchers, and healthcare professionals are generally unaware of how diet influences COVID-19, but consumption of a well-balanced diet to encourage normal B-and T-cell functioning could be helpful (Jaggers et al., 2020). Chronic pathologies in COVID-19 patients (Brugliera et al., 2020) may decrease the micronutrient status of the body, hence increasing their demands from recommended dietary allowances (Thibault et al., 2020), so eating a balanced diet and maintaining a healthy lifestyle is vital (FAO, 2020).
Diet is not a cure for COVID-19, but it is a modifiable factor in its development (Kamyari et al., 2021) that can help minimize infection progression and enhance recovery (Aman & Masood, 2020). Specific nutrients can influence the immune system by activating cells, altering signals and gene expression, and determining gut microbial composition. Among those important micronutrients are zinc, vitamins A, D, E, B6, B12, and C (Jaggers et al., 2020;Naja & Hamadeh, 2020), and the macronutrients are proteins and polyunsaturated fatty acids (Messina et al., 2020;Thibault et al., 2020). Certain other nonnutritional food constituents have also been reported productive for immune system modulation, such as polyphenols and flavonoids (Manzoor et al., 2017(Manzoor et al., , 2019Messina et al., 2020). People with a healthy immune system will battle COVID-19 in a better way (Nizami & Uddin, 2020).
In around 80% of COVID-19 infected patients, the disease will be mild to moderate, confined to the upper respiratory tract, and can be managed at home with proper care and conservative symptomatic therapy (Chowdhury et al., 2020). The individual responsibility of the whole of human relies on making an effort to live a balanced lifestyle, consume a diet rich in fruits and vegetables, exercise regularly, maintain a healthy weight, and get enough sleep (Naja & Hamadeh, 2020).
Hence, this whole scenario has generated a need to learn successful outcomes from those who have recovered with a minimum recovery period and with minimum pathophysiology. Therefore, this crosssectional survey-based study was conducted to recognize successful nutritional and lifestyle changes adopted by COVID-19 patients for rapid recovery during home quarantine in Punjab, Pakistan.

| Survey methodology
The survey was conducted from November 2020 to February 2021.
Patient inclusion criteria for the study were that they had completely recovered from COVID-19 infection at home. Patients with a confirmed case of COVID-19 detected by recommended methods (Hariri & Narin, 2020;NIH, 2020) such as reverse transcription-polymerase chain reaction (RT-PCR), chest computerized tomography (CT) scans, and serological enzyme-linked immunosorbent assay (ELISA) for IgG/IgM antibodies were given preference, but a few cases with a physician's strong suspicions were also included. In the period of the study, a total of eighty (n = 80) COVID-19 healthy recovered, home isolated, Pakistani nationals/residents from different cities of Punjab were contacted by phone to complete the questionnaire (collection of data) and to confirm reports of their COVID-19 diagnosis. All participating patients were preinformed and guided about the study objectives, including that the given information was only required for positive outcomes and only selected outcomes were to be shared according to the privacy policy, and their identity and contacts will not be disclosed at any point. A purposive selection of COVID-19 healthy recovered (age ≥14 years) patients was done without discriminating higher consumption of fast/fried/junk/spicy foods and cold water/drinks, were also significantly associated with a longer recovery period. The results were similar for not taking daily doses of multivitamins, and vitamins C, D, E, and zinc. This study identified that staying physically active, maintaining sensible body weight, having a sleep of 7 hr, consuming more foods of plant origin especially plant-based proteins from nuts and legumes, taking supplemental doses of multivitamins, vitamin D, E, and zinc, along with drinking ≥2 L of water daily can provide a significant role in early and safe recovery from COVID-19.

K E Y W O R D S
COVID-19, lifestyle, nutrition, recovery, vitamin supplements gender or clinical, nutritional, and socio-economical background for reducing biasness and enrichment of data.

| Development of a questionnaire for COVID-19 recovered patients
A questionnaire was developed by making some appropriate changes and additions after pilot testing of a questionnaire conducted by Di Renzo et al. (2020). The questionnaire was composed of seventy questions on the following ten categories: (I) personal data (four questions on age, gender, occupation, hometown); (II) anthropometrics (four questions on height, weight, BMI, body weight change); (III) COVID-19 updates (four questions relevant to infection and detection); (IV) apparent symptoms (fourteen questions); (V) past medical history (four questions on lung disease (bronchitis/asthma), autoimmune disorders (arthritis/allergies/hypersensitivities), chronic diseases (cardiovascular/hypertension/renal), and diabetes mellitus); (VI) nutritional changes (twenty two questions on dietary consumption patterns); (VII) nutritional supplements and drugs (seven questions on taking multivitamins and/or individual nutrients, and medications including analgesics, antipyretics, and antibiotics); (VIII) lifestyle changes (six questions on smoking, sleeping hours (≤5, 6, 7, 8, 9≥), physical activity (very active, fairly active, less/not active), steam inhalation, blood pressure, blood glucose, oxygen level monitoring); (IX) recovery time (two questions on days quarantined, days for complete recovery) and (X) post-traumatic stress disorder (PSTD) (three questions on stress/anxiety, fears, PSTD). The questionnaire has been attached in the Appendix 1. The questionnaires were completed by telephone call, and WhatsApp was used to collect reports of COVID-19 diagnosis. Once completed, survey answers were transferred to a Microsoft Excel spreadsheet.

| Statistical analyses
Numerical data were tabulated in Excel spreadsheets and analyzed using SPSS-16 software (IBM). Associations and correlations were calculated among different variables. Statistics from the following analyses were tabulated and used to interpret the results: Chisquared (χ 2 ), likelihood ratio (LR), linear by linear association (LA), Lambda (λ), Goodman and Kruskal tau (GK), gamma (Γ), Spearman's correlation (r s ), Pearson's R (r p ), and frequency distribution. An independent sample t test was applied for comparison. The significance level was set as p < .05 (*p ≤ .05; **p ≤ .01; ***p ≤ .001).

| COVID-19 infection, detection, and recovery
It is clear from Figure 1a that most patients had no idea from where they became infected with COVID-19. On the other hand, gatherings like wedding ceremonies, religious festival (Eid), funerals, market places, and family members were among major infection contributors. Places of work, hospitals, and educational establishments were also of significance for transmitting the virus. The modes for COVID-19 detection vary widely, but the criteria for mode selection depend upon the economical feasibility of patients and physician's preferences. The mode most adopted for detection was RT-PCR as shown in Figure 1b. The IgG/IgM antibodies test was least used for detection on its own; rather it was used in combination with other detection modes for confirmation purposes.
Results on COVID-19 exposure revealed that 44.8% of patients had COVID-19 infected members in their family during the past month, while 37.5% had a travel history to an infected area. The most common recovery time was reported as 2 weeks followed by 3 weeks as shown in Figure 1c, while some recovery was also reported in the first week. The overall mean recovery period was 2.8 ± 1.4 weeks or 19.2 ± 10.5 days.  results of the t test also support a difference in variances between male and female patients for recovery (t = 1.988, p = .050*), and similarly, data from Figure 2d also demonstrate more male patients with fourteen or more days of recovery. The age distribution in Figure 2c reveals that recovery longer than 3 weeks was more associated with increased age. Among different age groups, the highest frequencies for COVID infection were reported for students aged 23 years and professionals aged 34 years. The statistical comparison of age versus recovery time revealed significant associations and correlations (LA =6.925, p = .008***; λ = 0.284, p = .000***; Γ = 0.223, p = .001***; r s = 0.310, p = .005***; r p = 0.296, p = .008***), indicating an ordinal slight positive increase in recovery time with increasing age. To analyze the differences between age groups at 40 (<40 and ≥40), a t test was applied, for which highly significant results were obtained (t = 3.074, p = .003***).

| Age, gender, BMI, and body weight change in COVID-19
BMI was calculated from the given data on height and weight by applying the Quetelet equation (body weight in kg/height in m 2 ) and categorized according to WHO criteria (Pi-Sunyer, 2000) into the following five groups: (a) normal weight (18.5-24.99 kg/ BMI was shown to have a significant dependency on recovery time (χ2 = 1.275, p = .027*; λ = 0.219, p = .000***). Bodyweight changes with COVID-19 infection were reported as gain (20%), loss (35%), and stability (45%) and were found to significantly affect the recovery period (λ = 0.341, p = .005***). Patients who reported a loss in body weight were shown to have late recoveries as indicated in Figure 2b, Table 2.

| Past medical history and apparent symptoms in COVID-19 infection
Results for past medical history are shown in Figure 3a.
Surprisingly, there were no significant associations or correlations of lung and chronic disease with a recovery period. But results for autoimmune disorders were highly significant (χ2 = 47.251, p = .001***; GK =0.591, p = .001***). There was a significant ordinal negative correlation (Γ = −0.361, p = .038*) between diabetes and recovery, which indicates a slight ordinal decrease in diabetic patients along with an increase in recovery as well as more diabetes mellitus patients clustered around the late recovery zone as shown in Figure 2f.
The percentage distribution of apparent symptoms is represented in Figure 4a. The most dominant symptoms (>80%) were fatigue, fever, loss of senses, and muscular pain, while a cough, sore throat, and breathing difficulty were fairly dominant (60%-80%).
Symptoms like chest pain, drowsiness, and confusion were 40%-60% distributed, while headache and irritable bowel syndrome (IBS) were least distributed (<20%). The presence of a sore throat, cough, breathing difficulty, fever, fever consistency, fever intensity, drowsiness, and chest pain had significant associations and correlations with the recovery period, as shown in Table 3. Muscular pain, loss of senses, confusion, headache, and IBS were nonsignificant on recovery. The symptoms distribution along with recovery period in Figure 5 also shows the distribution of more consistent symptoms like sore throat, cough, breathing difficulty, fever, and fatigue in the delayed recovery zone, which supports their delaying effect beyond 2 weeks.

| Lifestyle changes
The patients' responses for sleep hours were distributed from 3 to 10 hr with a mean of 7.1 ± 1.3 hr. The most frequently adopted lengths of sleep were 8 hr (40%), followed by 6 hr (35%), 7 hr (15%), ≥9 hr (6.2%), and ≤5 hr (3.8%). Statistical analysis revealed that length of sleep had a highly significant association with the recovery of patients (λ = 0.333, p = .003***). The sleep hour distribution ( Figure 6d) revealed that 7 hr of sleep were less likely to be associated with late recovery. This association was strengthened by the results of a t test of comparison at <seven and ≥7 hr (t = −2.247, p = .027*).
Only 8.8% of patients claimed that they smoked, and this had no significant association or correlation with the recovery period. There were 35% of patients reported to take steam inhalation daily during COVID-19 infection, and statistical analysis showed a significant association with recovery (LA =3.811, p = .051*; Γ = 0.309, p = .027*; r s = 0.237, p = .034*; r p = 0.220, p = .050*). There were 66.2% of patients who faced anxiety/stress during quarantine, while 63.8% claimed to have fears including fear of death or disease transmission to others and being a cause of their death. Almost 17.5% claimed to face PSTD even after their complete recovery. Here, statistical analyses revealed no significant associations with recovery.
The results for physical activity before their COVID-19 infection revealed that 46.2% of patients were active by doing regular walks, while only 6.2% had a very active status by doing gym/ running/yoga/exercise. The remaining 47.5% were not engaged in any physical activity beyond their daily chores. During COVID-19 infection quarantine, patients with an active status increased to 51% by motivating them to do indoor walks, while those who had a very active status remained persistent by changing the mode of their activities to weightless workouts/yoga. The remaining 42.5% were not engaged in any kind of physical activity during quarantine. Statistical analysis revealed a significant association of physical activity before COVID-19 infection with recovery (LA =4.244, p = .039; λ = 0.333, p = .026*; r s = 0.232, p = .039*). On further comparison between physically active and nonactive status with recovery, significant variances were reported (t = 2.153, p = .034*).
Being physically active during COVID-19 infection quarantine was also found to be significantly associated with the recovery period (λ = 0.308, p = .029*). It is clear from Figure 6

| Dietary modifications
3.5.1 | Major food consumption pattern followed The major food consumption (%) pattern is shown in Figure 4b. The water intake of patients ranged from 0.75 to 2.5 L. Only 16.2% drank more than 2 L per day, while 23.8% drank about 2 L daily.
The most common consumption volume was 1.5 L by 46.2%, and the least common consumption volume was 0.75 L by only 2.5%.

| Major dietary changes (foods added/avoided/ meal changes)
Dietary changes (%) that were made during COVID-19 infection include the addition or exclusion of some foods. Major additions were meat, broths/soups, fruits, vegetables, eggs, nuts, ginger, green tea, and citrus, while major exclusions were rice, cold drinks/water/ cola, spicy, and junk/fast/fried foods, as shown in Figure 4c. Only the addition of meat showed significant dependency on recovery (λ = 0.261, p = .052*). The addition of more soups or broths, vegetables, nuts, and citrus showed slight dependencies that were nonsignificant. Green tea was taken by 57.5% of patients regularly during quarantine, and 17.5% claimed to add ginger in their tea, where ginger has a slight dependency on recovery, but it was not significant.
Senna makki (Senna alexandrina) herb was adopted by only 7.5% of patients as a remedial use for which statistical results revealed no significant association with the recovery period.
Among the most avoided items were junk/fast/fried foods in 56.2% patients, and these had significant effects on recovery In the current study, 41.2% added a meal or snack, 20% skipped a meal, and 38.8% had no change in their diet as it was already considered to be healthy. The recovery period showed dependency toward changes in meals/snacks (λ = 0.383, p = .000***); therefore,  during COVID-19. Statistical analysis revealed that this positive attitude about their improvement in diet also influenced the recovery period significantly (λ = 0.217, p = .053*).

| Major nutritional supplements and drugs taken
To meet additional nutritional requirements and to fulfill any existing deficiencies, 41.2% of patients took daily supplemental doses of multivitamins that were found to be significant on recovery (λ = 0.273, p = .044*). Here, 42.5% added a vitamin C supplement that was also significant on recovery (λ = 0.382, p = .016**). Zinc was taken daily by 30% and was found to be significant (λ = 0.333, p = .028*), and vitamin D (23.8%) also showed significant results (λ = 0.211, p = .04*).
Among the most used type of drugs were antipyretic analgesics (Panadol =86%, Nims =7.6%, and acetaminophen =6%) taken by 65% of patients, while the second most used type of drugs were antibiotics (47%) (Azomax/Azithromycin =92%), but the results for the drugs used in this study were not significant.  (Bwire, 2020). Not only were men more exposed to COVID-19 infection, but also the results for a delayed recovery period were also more distributed among men as compared to women (Figure 2d).

| D ISCUSS I ON
These results are in agreement with other published works that correlate males with a higher severity, morbidity, and mortality due to COVID-19 (Griffith et al., 2020;Peckham et al., 2020;Pradhan & Olsson, 2020). The whole scenario of females having an advantage against COVID-19 could be due to the prevalence of gender variations in both innate and adaptive immune systems. Especially in the adaptive immune system, where females have more CD4+ T cells, more robust CD8+ T-cell cytotoxic activity and improved B-cell immunoglobulin output than males (Peckham et al., 2020).
The results on age distribution showed significant associations with recovery, which ultimately concluded delayed recoveries in older age (Figure 2c). This was especially significant after the age of forty, and this outcome is supported by other studies claiming that in comparison with younger patients, elderly patients are more vulnerable to COVID-19 infection and have a worse outcome, primarily due to decreased or compromised immune functioning (Chowdhury et al., 2020;Silverio et al., 2020;Verity et al., 2020). Other factors contributing to this recovery delay in older age could be emotional distress, fears associated with isolation, health vulnerabilities, comorbidities, and dependency (Morrow-Howell et al., 2020;Shahid et al., 2020).
In our results, BMI association was also found to be significant on the recovery period and this is supported by Silverio et al. (2020) who claimed that obesity is widespread among COVID-19 infected hospitalized patients. Obesity can be a cause of impaired immune response and delayed recovery and hence can serve as an independent risk factor for the severity of COVID-19 pathogenesis (Morais et al., 2020). Reasons behind this association could be the link of obesity with lower expiratory volume and functional capability of the respiratory system. Especially in patients with elevated abdominal obesity, reduced diaphragmatic excursion can compromise pulmonary functions. Moreover, increased inflammatory cytokines linked to obesity can also play a role in the rise of the negative prognosis, which could ultimately delay recovery (Cena & Chieppa, 2020;Dietz & Santos-Burgoa, 2020;Popkin et al., 2020). Not only does increased weight has negative outcomes associated with recovery, but also unnecessary weight loss during the infection period was also found to be more prevalent in patients with late recoveries ( Figure 3b). This unplanned weight loss could be due to a disturbing hunger pattern, nausea, or diarrhea due to IBS and/or higher energy and protein utilization by the body to fight infection. Not eating properly could result in malnutrition (Anker et al., 2021;Filippo et al., 2020), which can impair the immune strength and ultimately delay recovery.
As far as the results for previous medical history were concerned, the prevalence of autoimmune disorders and diabetes mellitus imparted significant delays in recovery, as these can impair the immune system and ultimately serve as a risk factor for delayed recovery from COVID-19 (Alagawany et al., 2021; Silva et al., 2020;. Smoking was found to be nonsignificant on the recovery period in our results, which agrees with the study by Rossato et al. (2020), but is in contrast to the study by Reddy et al. (2021). While comparing a number of studies, the effect of smoking on COVID-19 infection has been identified as controversial (Polverino, 2020 (Calder, 2020). Another reason could be the presence of daidzein and genistein in legumes that are predicted to be bioactive compounds for COVID-19 treatment (Brahmaiah & Ankit, 2020). Similar is the case for nuts consumption that are rich in anti-inflammatory omega-3 polyunsaturated fatty acids, antioxidative and immunesupporting minerals like zinc and selenium, and bioactive peptides that could be a reason behind their significant association with recovery (Kieliszek & Lipinski, 2020;Zabetakis et al., 2020). Fruits being rich in vitamins, minerals, and antioxidants were also significant during the recovery period. Riboflavin and beta-carotene in fruits are especially among proven bioactive compounds against COVID-19 (Brahmaiah & Ankit, 2020). A decrease in milk and/ or yogurt consumption revealed a highly significant increase in the recovery period based on their inverse/negative correlations.
The reason behind this apparent protection could be the rich riboflavin content in milk that is a bioactive compound against COVID-19 (Brahmaiah & Ankit, 2020) and the rich microbiotics in yogurt that help in enhancing immunity (Antunes et al., 2020;Dhar & Mohanty, 2020). Among the results for major dietary changes in the study, the addition of meat was found significant, while all other remedial measures of taking green tea with or without ginger or taking senna makki (Senna alexandrina) herb, or eating garlic were nonsignificant. The avoidance of unhealthy dietary patterns including consumption of fast/fried/junk/spicy foods and cold drinks/sodas were found to be significant steps toward fast recovery. The use of vitamins C, D, E, and zinc as additional daily supplemental doses was found to be significant and was supported and suggested in COVID-19 patients by various studies (Cena & Chieppa, 2020;Chowdhury et al., 2020;de Faria Coelho-Ravagnani et al., 2020;Fernández-Quintela et al., 2020;Iddir et al., 2020;Jayawardena et al., 2020) for the nutritional management of the disease. Other studies have supported the intake of vitamins and minerals, especially vitamin D, which was found to be deficient in COVID-19 patients (Im et al., 2020;Kohlmeier, 2020

| LIMITATI ON S AND S TRENG TH S OF TH E S TU DY
Limitations of the current study were a relatively small sample size because of a limited number of patient readily participating, difficulties in getting access to the positively detected, healthy recovered COVID-19 patients, collecting all of the data on lengthy telephone calls, and limited resources due to no funding or supporting authorities. Similarly, the whole data reported by patients on anthropometrics, apparent symptoms, and past medical history were based on a patient's true knowledge. On the other hand, the strength of this study is its uniqueness as this type of cross-sectional study was not conducted before in Punjab and/or Pakistan during the COVID-19 pandemic according to current knowledge. There are plans to expand the study to larger sample size and geographical area using electronic online survey methodology and proper funding.

| CON CLUS ION
Timely nutritional and lifestyle changes can help us save our future generations. Based on this study, we have concluded many beneficial nutritional guidelines by examining the nutritional patterns adopted by COVID-19 recovered home quarantined patients. A healthy lifestyle with appropriate sleep hours, steam inhalation, and physical activity could help fight COVID-19 infection more effectively and/ or more quickly. Similarly, increased water consumption, along with more intakes from plant-based organic home-cooked foods, while omitting nonhealthy junk and fast foods also facilitate early recovery. Taking a daily supplemental dose of selected vitamins (C, D, E), minerals (zinc), or taking them in combination as a daily multivitamin and mineral dose can enhance the body's ability to fight the infection and could facilitate early recovery. The outcomes of this study are very comprehensive and have set down a nutritional and lifestyle base for health promotion, early recovery, and a positive survival rate against the COVID-19 pandemic. Considering all the above positive outcomes, we can modify our lifestyle to have a safe journey toward a future free of COVID-19 generated fears.