Is the BRAT (Bland, easily digestible foods: Bananas, Rice, Applesauce, Toast) diet still recommended for acute diarrhea in COVID-19 patients?

The BRAT Diet is No Longer Recommended for Acute Diarrhea in COVID-19 Patients

The BRAT (Bananas, Rice, Applesauce, Toast) diet is not recommended for acute diarrhea in COVID-19 patients as it does not meet nutritional requirements needed for recovery and immune function. 1 Instead, a nutritionally complete diet with adequate protein and calories is essential for COVID-19 patients experiencing gastrointestinal symptoms.

Current Nutritional Recommendations for COVID-19 Patients with Diarrhea

Understanding Diarrhea in COVID-19

• Diarrhea affects approximately 10-20% of COVID-19 patients 2
• Can occasionally be the presenting and only COVID-19 symptom
• Usually mild-to-moderate and non-bloody, but can sometimes be profuse
• May be caused by direct viral infection (via ACE2 receptors in GI tract), medication side effects, or secondary infections like C. difficile 2

Recommended Nutritional Approach

1. Nutritional Risk Assessment

   • All COVID-19 patients should be screened for malnutrition using validated tools like MUST or NRS-2002 1
   • Up to 65% of COVID-19 ICU patients may be malnourished 1

2. Dietary Recommendations

   • Provide adequate protein: 1g protein per kg body weight per day 1
   • Ensure sufficient calories: 27-30 kcal per kg body weight per day 1
   • Use high-protein, polymeric formulas rather than restrictive diets 1
   • Maintain hydration status with adequate fluid intake and electrolyte replacement 2

3. Management of Acute Diarrhea

   • Symptomatic treatment with antidiarrheal medications like loperamide when appropriate 2
   • IV fluid replacement if needed for severe cases 2
   • Monitor for C. difficile infection, especially in patients receiving antibiotics 2

Why BRAT Diet is No Longer Recommended

The BRAT diet has several limitations that make it unsuitable for COVID-19 patients:

• Inadequate protein content: COVID-19 patients require higher protein intake (1-2g/kg/day) to combat catabolism and support immune function 1
• Insufficient calories: The restrictive nature of BRAT diet cannot meet the increased energy demands of COVID-19 patients 1
• Limited nutritional value: Lacks essential vitamins and minerals needed to support immune function 1, 3
• No evidence of efficacy: No clinical evidence supports using BRAT diet for COVID-19 diarrhea management 1

Practical Nutritional Management for COVID-19 Patients with Diarrhea

1. Acute Phase

   • Ensure adequate hydration and electrolyte replacement
   • Provide easily digestible, nutrient-dense foods
   • Consider oral nutritional supplements if intake is inadequate 1
   • Use antidiarrheal medications as appropriate 2

2. If Oral Intake is Insufficient

   • Consider enteral nutrition via nasogastric tube within 24-48 hours of admission 1
   • Use standard, high-protein enteral formula 1
   • Consider formulas with EPA and DHA for potential immunomodulatory effects 1

3. For Severe Cases

   • If enteral nutrition is contraindicated, consider parenteral nutrition 1
   • Monitor for refeeding syndrome when reintroducing nutrition 4

Special Considerations for Long COVID

For patients with persistent GI symptoms as part of Long COVID:

• Gastrointestinal symptoms including constipation are common in long COVID 5
• Nutritional support plays an important role in meeting requirements and aiding recovery 5
• Targeted nutritional therapy may help address fatigue and other persistent symptoms 5

Common Pitfalls to Avoid

• Restricting diet unnecessarily: This can worsen nutritional status and impair recovery
• Delaying nutritional support: Early intervention is crucial for preventing malnutrition
• Ignoring protein needs: Adequate protein is essential for immune function and recovery
• Overlooking hydration status: Fluid and electrolyte replacement is critical in diarrhea management
• Failing to monitor for C. difficile: Always consider this in hospitalized patients with diarrhea, especially those on antibiotics

In conclusion, while the BRAT diet was historically recommended for acute diarrhea, current evidence and guidelines support a more comprehensive nutritional approach that ensures adequate protein, calories, and nutrients for COVID-19 patients experiencing diarrhea.