Weight Loss With Long COVID in South Africa
Long COVID has affected hundreds of thousands of South Africans — and weight management during recovery is complicated. Some gain weight from inactivity and medication side effects; others lose weight unintentionally from appetite loss and hypermetabolism. This guide explains both situations and what to do.
Medical disclaimer: Long COVID is a complex, evolving condition. This article is for informational purposes only. Always consult your doctor before starting any diet or exercise programme post-COVID, especially if you experience post-exertional malaise (PEM).
What Is Long COVID?
Long COVID (also called post-acute sequelae of SARS-CoV-2, or PASC) is defined as symptoms persisting or developing more than 4 weeks after a COVID-19 infection. The WHO estimates that 10–20% of COVID-19 infections lead to long COVID symptoms lasting beyond 3 months. In South Africa — which experienced four major waves with relatively low vaccination uptake in the early period — the burden is significant.
Common long COVID symptoms affecting weight and metabolism include:
- Fatigue and post-exertional malaise (PEM) — extreme tiredness after minimal activity
- Brain fog — cognitive impairment affecting meal planning and motivation
- Dysautonomia — autonomic nervous system dysfunction causing heart rate spikes, nausea, and dizziness on standing
- Loss of smell/taste (anosmia/ageusia) — reduces appetite and food enjoyment
- Sleep disruption — affects hunger hormones (ghrelin and leptin)
- Anxiety and depression — associated with emotional eating patterns
- Joint and muscle pain — limits physical activity
Why Long COVID Causes Weight Gain
Weight gain after COVID is common and has multiple overlapping causes:
1. Forced Inactivity
During acute illness and the recovery period, most people are largely bedbound or housebound. Physical activity drops dramatically while food intake continues. Even at maintenance calories, weight gain occurs because caloric burn falls. For long COVID patients with PEM, this inactivity can persist for months or years.
2. Corticosteroid Treatment
Dexamethasone became standard-of-care for severe COVID-19 in South African hospitals from mid-2020 onwards. Corticosteroids cause rapid fluid retention (2–5 kg), increase appetite, redistribute fat to the abdomen, and can cause insulin resistance. Short-course steroids typically reverse within weeks; longer courses may cause more persistent weight gain.
3. Disrupted Sleep and Stress Hormones
Long COVID frequently causes unrestorative sleep. Poor sleep elevates cortisol (promoting abdominal fat storage) and ghrelin (hunger hormone) while suppressing leptin (satiety hormone). The result is increased appetite, cravings for high-calorie foods, and preferential fat storage around the abdomen.
4. Comfort Eating and Mental Health
Long COVID carries significant psychological burden. Rates of depression and anxiety among long COVID patients are 2–3 times higher than baseline. South Africa's high baseline stress levels (economic pressure, load shedding, job losses post-pandemic) compound this. Emotional eating is a natural response — but a cycle that drives weight gain.
Why Long COVID Can Also Cause Weight Loss
Not all long COVID patients gain weight. Some experience significant unintentional weight loss due to:
- Persistent anorexia — loss of appetite lasting weeks to months post-infection
- Dysphagia — difficulty swallowing (common after ICU intubation or severe COVID)
- Gastrointestinal symptoms — nausea, diarrhoea, gastroparesis (slowed stomach emptying)
- Dysautonomia-related nausea — particularly with postural orthostatic tachycardia syndrome (POTS)
- Increased resting metabolic rate — chronic inflammation elevates calorie burn
When to see a doctor urgently: Unintentional weight loss of more than 5% of body weight over 3 months warrants medical review. In long COVID patients, this can indicate malabsorption, ongoing inflammatory activity, or metabolic complications requiring assessment.
The Critical Issue: Post-Exertional Malaise (PEM)
PEM is not "just being tired." Post-exertional malaise is a defining feature of ME/CFS (myalgic encephalomyelitis/chronic fatigue syndrome), which overlaps significantly with long COVID. PEM means that physical or cognitive exertion causes a worsening of symptoms that may last 12–72 hours after the activity. Pushing through PEM — "no pain, no gain" thinking — can cause permanent setbacks in long COVID recovery. If you have PEM, the exercise advice below does NOT apply to you. Focus on pacing instead.
How to Identify PEM
Ask yourself: after exercise or activity, do your symptoms (fatigue, brain fog, pain) worsen the following day or two days later? If yes, this is PEM. Track your symptoms for one week after any moderate activity using a simple diary or app.
Exercise With Long COVID: What Actually Works
If You Have PEM: Pacing, Not Exercise
Energy management (pacing) is the evidence-based approach. Stay below your "anaerobic threshold" — the point where symptoms worsen. This may mean resting before you feel exhausted, limiting all activity (physical and cognitive), and gradually expanding capacity over weeks to months under medical supervision. The Heart Rate Method for pacing: keep heart rate below 110 bpm (or your age-specific estimate of 50–60% of max HR) at all times.
If You Don't Have PEM: Graduated Exercise Return
A 5-phase graduated return to exercise (adapted from the UK NICE long COVID guidelines) is appropriate:
| Phase | Activity | Duration |
|---|
| 1 | Stretching, light household activity | 10–15 min daily, 1+ week |
| 2 | Slow flat walking | 15–20 min, 1+ week |
| 3 | Brisk walking, light cycling | 20–30 min, 1+ week |
| 4 | Moderate intensity exercise, light resistance | 30–45 min, 1+ week |
| 5 | Return to previous exercise levels | Ongoing |
Progress to the next phase only if previous phase causes no symptom worsening. Stay at any phase for as long as needed.
The Long COVID Anti-Inflammatory Diet
Chronic low-grade inflammation is central to long COVID pathology. An anti-inflammatory diet supports recovery and helps manage weight by reducing inflammatory-driven fatigue, improving insulin sensitivity, and supporting gut microbiome recovery (COVID-19 significantly disrupts gut bacteria).
Prioritise These Foods
Long COVID recovery foods — available in South Africa:
- Omega-3 rich fish — pilchards, sardines, mackerel (R20–R35/can) reduce neuroinflammation and support lung recovery
- Colourful vegetables — tomatoes, sweet peppers, butternut, sweet potato, leafy greens (morogo, spinach)
- Fermented foods — plain yoghurt, amasi (maas), sauerkraut — support microbiome recovery
- Rooibos tea — rich in anti-inflammatory polyphenols aspalathin and nothofagin; caffeine-free, safe in large quantities
- Turmeric with black pepper — curcumin reduces neuroinflammation; add to cooking
- Ginger — anti-nausea, anti-inflammatory; fresh ginger tea useful for dysautonomia-related nausea
- Legumes — lentils, beans, chickpeas; high fibre supports microbiome, affordable at R15–R30/400g tin
- Eggs — complete protein for muscle preservation, choline supports brain fog recovery
- Avocado — anti-inflammatory monounsaturated fats, potassium for dysautonomia/POTS management
Limit or Avoid
- Ultra-processed foods — drive inflammation, worsen gut microbiome disruption
- Sugary drinks and refined carbohydrates — glucose spikes worsen fatigue and brain fog in long COVID
- Alcohol — worsens long COVID fatigue, disrupts sleep, worsens neuroinflammation
- Excessive caffeine — can worsen heart palpitations in dysautonomia; switch to rooibos or herbal teas
- High-sodium foods — worsen fluid retention in patients with post-COVID hypertension
Protein for Muscle Preservation
Long COVID causes significant muscle wasting (sarcopenia), even in patients who weren't severely ill. Maintaining muscle mass is important for long-term weight management and recovery. Target 1.2–1.6g protein per kg of body weight per day. Spread protein intake across meals rather than eating it all at once — this maximises muscle protein synthesis.
Sample Long COVID Recovery Day:
Breakfast: 2-egg omelette with spinach and feta + rooibos tea
Mid-morning: Plain yoghurt (amasi or Danone Full Cream) + mixed berries or banana
Lunch: Pilchards on 2 slices seed bread + large mixed salad with olive oil + ginger-lemon water
Afternoon: Small handful of walnuts or 2 Brazil nuts + rooibos
Dinner: Lentil and vegetable curry with brown rice + 1 tsp turmeric in cooking
Approx 1,400–1,600 kcal | 80–100g protein | Anti-inflammatory, gut-supportive
Managing POTS and Dysautonomia Weight Challenges
Postural orthostatic tachycardia syndrome (POTS) is common in long COVID and causes heart rate spikes, nausea, and dizziness on standing. This makes conventional weight loss approaches problematic:
- High sodium intake (3–5g/day above normal) is often prescribed for POTS to maintain blood volume — this conflicts with standard weight loss advice to reduce sodium
- Increased fluid intake (2.5–3.5L/day) is standard POTS management
- Compression garments worn from waist down reduce blood pooling and may make walking more tolerable
- Eating smaller, more frequent meals reduces post-meal blood pooling that worsens POTS symptoms
- Reclining or seated exercise (recumbent cycling, pool exercises, rowing machine) avoids upright positions that worsen POTS
If you have POTS-type symptoms post-COVID, discuss with your cardiologist or GP before following standard weight loss dietary advice — the sodium and fluid rules are different.
Mental Health and Emotional Eating in Long COVID
The psychological burden of long COVID is substantial. Being unable to work, losing fitness, having symptoms dismissed by others ("but you look fine"), and uncertainty about recovery creates fertile ground for emotional eating and disordered eating patterns.
Practical strategies:
- SADAG (South African Depression and Anxiety Group) provides free telephonic counselling: 0800 567 567 (8am–8pm)
- Acknowledge that weight gain during illness is normal and not a personal failure
- Structure mealtimes even if appetite is poor — regular eating stabilises blood sugar and hunger hormones
- Mindful eating practices (eating without screens, savouring food) can help when taste/smell is altered
- If taste is absent, focus on texture and temperature variety to maintain eating interest
South African Support Resources
- Long COVID SA — patient community and resources at longcovidsa.co.za
- NICD — ongoing COVID-19 data at nicd.ac.za
- SASP (South African Society of Physicians) — long COVID clinical guidance
- Medical aid coverage — long COVID rehabilitation may qualify under CDL for cardiac or pulmonary conditions; check with your scheme
- Post-COVID clinics — Groote Schuur Hospital (Cape Town), Charlotte Maxeke Academic Hospital (Johannesburg), Steve Biko Academic Hospital (Pretoria)
FAQ: Long COVID and Weight
Why did I gain weight after COVID-19?
Multiple factors: forced inactivity, corticosteroid treatment, disrupted sleep elevating hunger hormones, dysautonomia limiting movement, and emotional eating from the psychological burden of long COVID.
Is it safe to exercise with long COVID?
Only if you do NOT have post-exertional malaise (PEM). If exercise worsens your symptoms 12–48 hours later, pacing (staying below your energy threshold) is essential. Pushing through PEM can permanently worsen long COVID. Consult your doctor for a personalised plan.
What diet helps long COVID recovery?
An anti-inflammatory diet: omega-3 rich fish (pilchards, sardines), colourful vegetables, fermented foods (amasi, yoghurt), adequate protein (1.2–1.6g/kg/day), and rooibos tea. Avoid ultra-processed foods, alcohol, and excessive caffeine.
Can long COVID affect my weight even a year later?
Yes. Long COVID symptoms can persist for 2+ years in some patients. Ongoing fatigue, sleep disruption, and depression-driven eating continue to affect weight long after initial infection. This requires ongoing management, not a one-time intervention.
Sources: WHO Long COVID Definition 2021 | NICE Long COVID Guidelines NG188 | NICD South Africa COVID-19 Data 2024 | Davis HE et al, Nature Reviews Microbiology 2023 | SASP Long COVID Position Statement | South African Medical Journal 2023. Last reviewed June 2026.