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COVID-19 is a viral infectious disease caused by SARS-COV2. Its clinical signs and symptoms are on a broad spectrum ranging from asymptomatic to severe complications like multi-organ failure, thromboembolism, and severe pneumonia with respiratory failure. Worse outcomes and higher mortality rates have been reported in the elderly, people with co-morbidities, and malnourished individuals. Nutrition is fundamental to good health and immune function. It forms an integral component of treatment modalities for various acute and chronic diseases, especially where a causative treatment is not yet recognized. Taking into consideration the magnitude of demands this pandemic has posed on hospital resources, an orderly assessment of nutritional status and body composition may not be possible for critically ill and/or for patients with mild-moderate symptoms who are managing their illness at home. Adequate intake of various macro and micronutrients--energy, protein, fat, vitamins--A, B, C, D, E and minerals--iron, selenium, zinc, and copper, along with supportive health practices like hydration, meal consistency, frequency of meal consumption and physical activity, often ameliorate respiratory infections, in part by modulating the immune response. Though at present there is a lack of well-defined nutrition-based guidelines for COVID-19 patient care, this paper brings forward the existing relevant evidence base for caregivers and patients to use as a reference/guide. Introduction A novel coronavirus (SARS-CoV-2), causing serious respiratory illness like pneumonia and lung failure was first reported in Wuhan city, China at the end of 2019. It rapidly spread resulting in a global pandemic. As of Dec 15, 2020, COVID-19 has rapidly spread in more than 200 countries, areas or territories causing 71 million confirmed cases and more than 1,608,648 deaths (WHO, 2020). The clinical signs and symptoms of COVID-19 are on broad spectrum, ranging from asymptomatic infection to severe complications like multiorgan failure, thromboembolism, and severe pneumonia with respiratory failure (Kofman, 2020). The most common symptoms remain dry cough, fever and fatigue, and the symptoms may appear 1-14 days after exposure to the virus. Higher prevalence of infection and death have been reported in elderly people and people with immunocompromising conditions and/or co-morbidities like hypertension, diabetes, obesity, heart World Nutrition 2020;11(4):66-93 67 and lung problems. In the elderly, a deficient micronutrient status might contribute to a decreased immune function (Yang, 2020). However, all individuals are susceptible to this infection (WHO, 2020). Immune response in COVID-19 COVID-19 is not atypical of the way influenza virus or even the coronaviruses intrude in our bodies. Our immune system has a predictable response towards the surge of invading pathogens and soon the body’s immune system mediates its innate response. Viral interactions with the innate immune system determine the outcome of infection to a large extent. Type 1 interferons, complement proteins, and innate immune mediators control viral replication during the initial phases of the disease (Katze et al., 2002). The innate immune response stops virus replication, stimulates virus clearance and induces tissue repair, thereby initiating a sustained adaptive immune response against the virus. However, an aggressive innate immune response can be counterproductive and result in immune pathology and ensuing tissue damage (Garcia-Sastre and Biron, 2006). Spike proteins of SARS-CoV2 are able to gain entry by unlocking the angiotensinconverting enzyme 2 (ACE2) protein on the lung cells. In most SARS-CoV2 cases, the innate immune system, upon recognizing the virus, triggers pulmonary and systemic inflammatory responses leading to lung injury (Ortega et al., 2020). Therefore, it is critical to regulate cytokine production and inflammatory response in CoV-pneumonia cases, as they cause fluid buildup in the lungs. However, targeted inhibition of specific features of the immune response without compromising the assistance of host defense remains a challenge (Li et al., 2020). This implies that mortality rates are determined by the extent to which the immune response is tolerated by the body. In addition, the original gut bacteria in the host are known to create a defense against pathogens. However, the disease disruption breaks this barrier and supports the growth of pathogenic organisms. Administration of probiotic organisms are known to enhance the innate immunity more than the acquired immunity. These exogenous organisms act by creating a physical barrier against pathogens and generating metabolic end products like lactic acid that hinders the growth of pathogens (Thomas et al., 2010). Systematic reviews have suggested there are protective effects of probiotics particularly lactobacilli and bifidobacteria, towards respiratory tract infections (Laursen et al., 2018; Araujo et al., 2015). It is possible that these effects can have an impact on COVID-19. The metabolic and endocrine linkage Recent research has suggested the existence of a link between coronavirus infection and Type 2 Diabetes Mellitus (T2DM), obesity, hypertension, and respiratory distress syndrome. In fact, the most commonly occurring co-morbidities with SARS (Severe Acute respiratory syndrome) and MERS (Middle East respiratory syndrome) are T2DM and hypertension (Bornstein et al., 2020). SARS and MERS are both respiratory infections caused by the family of coronaviruses. According to US Centers for Disease Control (CDC) coronavirus reports, there is a ten-fold higher risk of mortality in patients with T2DM and metabolic syndrome. People with diabetes and uncontrolled blood glucose levels are immune-compromised which may lead them to an increased predisposition to COVID-19 infection (Casqueiro et al., 2012). The Angiotensin Converting Enzymes (ACE) 1 and 2 together regulate the angiotensin system of our body. When ACE1 activity World Nutrition 2020;11(4):66-93 68 is increased and ACE2 inhibited, angiotensin II sets off inflammatory responses along with secretion of aldosterone. Consequently, there is an increase in blood pressure and lowering of potassium levels in blood serum. SARS coronavirus on binding with ACE2 also reduces insulin release from the pancreas (Yang et al., 2010). Researchers have suggested that severe patients of COVID-19 might create an imbalance in the stimulation of these pathways, becoming more severe in an already weakened immune state (Bornstein et al., 2020). Obesity is also known to weaken the adaptive immune responses to influenza virus (Green et al., 2017). Furthermore, fat accumulation reduces cardioprotective and immune regulation efficiency. This intercedes the progression to critical illness and organ failure in severe COVID-19 patients (Sattar et al., 2020; Finucane and Davenport, 2020; Zhao, 2020). Like in any other infection, an undernourished COVID-19 patient would exert extra nutritional demands on the body to combat the severe acute inflammatory status and the development of malnutrition would result (Domingo et al., 2020). While hyperglycemia and T2DM may be independent predictors of mortality and morbidity in patients with SARS1 (SARS) and MERS-CoV (Yang et al., 2006), where obesity is an independent risk factor for COVID-19 needs further research (Zhao, 2020; Sattar et al., 2020). Management of COVID-19 Outpatient management is appropriate in patients with mild illness (majority of the patient population) and does not warrant hospitalization or medical intervention as is deemed necessary for patients with severe and critical manifestations (WHO, 2020). Adherence to appropriate infection control, isolation precautions for the duration of illness and recovery, adequate access to food, and assistance with activities of daily living are essential for successful home management (CDC, 2020). The treatment differs with the severity of illness, as each phase may require a specific treatment regime. Marik et al. (2020) have postulated a combined treatment strategy consisting of methylprednisolone, ascorbic acid, thiamine, and full anticoagulation with heparin, called as the MATH+ protocol for patients who are in the pulmonary phase of COVID-19. Notably, diet and nutrition form an integral part of the management regime for infections, ailments or acute and chronic diseases even where an etiologic treatment has not yet been substantiated like COVID19 (Laviano et al., 2020; Shakoor et al., 2020). Role of Nutrition in management of COVID-19 Malnutrition in both forms--undernutrition and overweight, has an impact on immune response to infections. This could be a result of neuroendocrine alterations and adipose tissue generated chronic inflammation. Concurrently, this interface exerts an adverse effect on food intake through mechanisms that include hormonal changes and cytokines (Krawinkel, 2012). The availability of nutrients in the host’s body determines and stimulates specific and non-specific defense mechanisms and immune responses towards the pathogen (Pereira, 2003; Weis, 2017; Assmann, 2018). An acute infectious state induces hyper catabolism in the body, subsequently causing further loss and depletion of body nutrient stores along with increased energy demands. Protein breakdown with a higher resting energy expenditure is characteristic of aggressive infections. As a consequence, there is a higher nutrient requirement for speeding up active and passive host resistance. The extent of this is defined by the type of micro-organism, severity of the disease, and the presence of other complications (Pereira, 2003). World Nutrition 2020;11(4):66-93 69 Associations exist between nutrient deficiencies and metabolic imbalances leading to increased risk of specific infections. The way this manifest is a vicious cycle, and thus whether the deficiencies and alterations are predisposing factor to in

Evidence that maintaining optimal nutrition status for well-functioning immune system might promote recovery for mild COVID-19 patients