Whether managing conditions that have been misunderstood for years or dealing with the newly described long Covid, far more research is needed to determine the overlap between medically unexplained symptoms and nutrient deficiencies

Long Covid is twice as common in women as in men, according to a study led by Dr Claire Steves and Professor Tim Spector of King’s College London. In patients who were hospitalised with Covid-19, working-age women were five times as likely to develop long Covid as men the same age.

The pattern emerging with long Covid has been seen in other conditions such as postural orthostatic tachycardia syndrome (POTS); mast cell activation syndrome (MCAS); myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS); functional neurological disorder (FND); and fibromyalgia. These also predominantly affect women.

With the exception of long Covid, which currently has the world’s gaze upon it, these other conditions all have similar issues in common: a lack of research and understanding leading to patients (especially women) often spending months or years trying to obtain a diagnosis. Even when a diagnosis is made, licensed drug treatments are lacking. Along the way patients may be told their test results are “normal” and that they have “medically unexplained symptoms”.

As a pharmacist, I know from experience that if a doctor repeats something that I have just said, he/she is more likely to be listened to than I am. Many women will have experienced a similar situation where a man has been listened to over them. On chronic illness forums and social media, women repeatedly talk of taking a man to their medical appointments because their testimony is taken more seriously. 

Emma Barnett, presenter of Woman’s Hour on BBC Radio 4, has talked about how she has experienced agonising heavy painful periods since their onset at 10 years of age. It took 21 years to get endometriosis diagnosed. 

Emma was fobbed off repeatedly over many years until a doctor friend suggested she seek further investigation. Emma’s book, ‘Period: It’s About Bloody Time’, aims to tackle unspoken and unacknowledged issues about menstruation. It addresses shame and stigma, and points out that many women suffer in silence because they perceive that is what society expects of them.

I too have personal experience of living with ill health symptoms since early childhood, the cause of which remained undiagnosed for decades. I realised at 40 years of age that my seemingly unconnected symptoms were related to an underlying heritable connective tissue disorder.
I had worked as a pharmacist in healthcare for 20 years and was studying for my third healthcare sciences-related degree when I realised that I have a condition that I had never heard of. There are no licensed drug treatments for the condition I have so it had never featured in my pharmacy training or continuing professional development.

So – why might women be affected with “medically unexplained symptoms” more often than men? Basically it is because these conditions predominantly affect women between the onset of menstruation and the menopause when women have periods, may experience pregnancy and be juggling a combination of running a home, working and life as a mother. Female reproductive hormones are often blamed so other issues may not be considered, discussed or investigated.

Female reproductive hormones are often blamed so other issues may not be considered, discussed or investigated

Food poverty

So let us now consider the role of nutrition.

The Covid-19 pandemic has pushed many families into food poverty. Between September 2020 and February 2021, nearly 6 million adults and 1.7 million children were experiencing food poverty, according to an Environment, Food and Rural Affairs select committee report. However, food poverty is not just a financial issue that relates to food vouchers and free school meals. 

Food poverty can lead to malnutrition, which has symptoms and health consequences – but malnutrition does not only affect individuals who are experiencing food poverty. Juggling work, and perhaps caring commitments, can put immense pressure on the time available for shopping and cooking. Combine all these issues together and it is easy to see why women might experience nutritional deficiencies more frequently than men. 

Many nutrient deficiencies are not routinely considered when a patient presents with new symptoms. Malnutrition may only be picked up by blood tests or perhaps when someone has experienced recent rapid and substantial weight loss. Within the NHS, iron, folate, vitamin B12 and vitamin D may be considered and measured relatively routinely. In primary care, supplementation of some nutrients may only be considered in certain circumstances (e.g. thiamine in alcoholism; calcium in osteoporosis).

For decades, magnesium has rarely been considered in primary care. Since the MHRA warning in 2014 about the possibility of hypomagnesaemia developing with proton pump inhibitors, it may now be considered more frequently. However, only about 1 per cent of the body’s magnesium is in the blood; the rest is in tissue and bone. Regulation of magnesium results in the body pulling it from elsewhere to keep blood levels within range. Consequently, a magnesium blood test may not pick up a clinical deficiency. Magnesium deficiency symptoms massively overlap with certain medically unexplained symptoms. Might an undiagnosed magnesium deficiency be the cause of medically unexplained symptoms in some people?

The drugs often used to treat medically unexplained symptoms are largely not licensed for these indications. Prescribing may be a trial and error approach. Some drugs that may be tried (e.g. proton pump inhibitors, NSAIDs, opioids, pain modulators, antidepressants, steroid creams and inhalers) may cause side-effects, or aggravate nutritional issues by interfering with absorption or even depleting nutrients.

If the drugs are ineffective, women may seek help and potential solutions elsewhere – and if the underlying issue appears to be a nutrient deficiency, they may seek nutritional advice. Some women (and I include myself in this group) have tremendous success with a nutritional approach. After studying for an MSc in nutritional medicine and experimenting on myself with dietary changes and nutrient supplements, I have been able to get all my lifelong symptoms under control. 

At the time of writing, it is almost seven years since I was last prescribed a medicine. As well as the personal health and wellbeing benefits to me, this has also saved both me and the NHS the need for medical appointments and prescription medicines.

Why is nutrition important in Covid-19?

Optimal nutritional status is needed to support a healthy immune system. Professor Philip Calder, professor of nutritional immunology at the University of Southampton, published a paper in April 2020 suggesting that vitamins A, B6, B9, B12, C, D, E and trace elements, including zinc, iron, selenium, magnesium and copper, are all needed to support the immune system when combating respiratory infection. 

These nutrients will be utilised, and stores may become depleted, during an acute Covid-19 infection. With gastrointestinal symptoms and loss of appetite, an individual may also reduce their nutritional intake during the acute infection phase.

Research from the Covid Symptom Study App has revealed six distinct groups. Those people who are categorised as Type 6 (severe level three, with abdominal and respiratory symptoms including loss of smell, loss of appetite, cough, fever, hoarseness, sore throat, chest pain, fatigue, confusion, muscle pain, shortness of breath, diarrhoea and abdominal pain) appear to have worse outcomes with Covid-19. Might this be related to compromised nutritional intake/absorption due to severe gastrointestinal symptoms?

As with most illnesses, the focus has largely been on pharmaceutical approaches to prevent and treat Covid-19 infection. Recommendations to utilise a nutritional approach to manage both the acute illness and long Covid have largely been ignored. 

Recommendations to utilise a nutritional approach to the management of acute Covid illness and long Covid have largely been ignored

So what next?

When we look at medically unexplained symptoms, including those appearing in long Covid, and compare these with some nutrient deficiencies, we can see a huge overlap. Once one nutrient deficiency sets in, and if the symptoms start to affect the gastrointestinal system, people may try to manage their symptoms by avoiding certain foods, creating a downward spiral.

We are dealing with a lot of uncertainty around long Covid and there is still a lot to learn. However, some healthcare professionals are exploring a potential nutritional solution to their own symptoms. Professor Trish Greenhalgh, professor of primary care at University of Oxford tweeted in October 2020: “Email from someone (medic) whose severe #longcovid fatigue has got 90 per cent better on B12 injections. Had low B12 documented in a blood work-up.” There was a follow-up tweet, which said: “This needs research don't you think?!!!”.

Professor Greenhalgh is right. We must not disregard nutritional issues when approaching symptoms that we do not understand and cannot explain. Whether dealing with conditions that have been misunderstood for years, or dealing with the newly-described long Covid, a lot more research is needed to see if the overlap between medically unexplained symptoms and nutrient deficiencies is association or causation.

Am I claiming that this is a panacea that is going to help everyone? Absolutely not – but there is a distinct possibility that it could help.