Covid-19 affects taste independent of taste-smell confusions: results from a combined chemosensory home test and online survey from a large global cohort.

People often confuse smell loss with taste loss, so it is unclear how much gustatory function is reduced in patients self-reporting taste loss. Our pre-registered cross-sectional study design included an online survey in 12 languages with instructions for self-administering chemosensory tests with 10 household items. Between June 2020 and March 2021, 10,953 individuals participated. Of these, 5,225 self-reported a respiratory illness and were grouped based on their reported COVID test results: COVID-positive (COVID+, N = 3,356), COVID-negative (COVID-, N = 602), and COVID unknown for those waiting for a test result (COVID?, N = 1,267). The participants who reported no respiratory illness were grouped by symptoms: sudden smell/taste changes (STC, N = 4,445), other symptoms excluding smell or taste changes (OthS, N = 832), and no symptoms (NoS, N = 416). Taste, smell, and oral irritation intensities and self-assessed abilities were rated on visual analog scales. Compared to the NoS group, COVID+ was associated with a 21% reduction in taste (95% confidence interval (CI): 15-28%), 47% in smell (95% CI: 37-56%), and 17% in oral irritation (95% CI: 10-25%) intensity. There were medium to strong correlations between perceived intensities and self-reported abilities (r = 0.84 for smell, r = 0.68 for taste, and r = 0.37 for oral irritation). Our study demonstrates that COVID-19-positive individuals report taste dysfunction when self-tested with stimuli that have little to none olfactory components. Assessing the smell and taste intensity of household items is a promising, cost-effective screening tool that complements self-reports and may help to disentangle taste loss from smell loss. However, it does not replace standardized validated psychophysical tests.

Massively collaborative crowdsourced research on COVID19 and the chemical senses: Insights and outcomes.

In March 2020, the Global Consortium of Chemosensory Research (GCCR) was founded by chemosensory researchers to address emerging reports of unusual smell and taste dysfunction arising from the SARS-CoV-2 pandemic. Over the next year, the GCCR used a highly collaborative model, along with contemporary Open Science practices, to produce multiple high impact publications on chemosensation and COVID19. This invited manuscript describes the founding of the GCCR, the tools and approaches it used, and a summary of findings to date. These findings are contextualized within a summary of some of the broader insights about chemosensation (smell, taste, and chemesthesis) and COVID19 gained over the last 18 months, including potential mechanisms of loss. Also, it includes a detailed discussion of some current Open Science approaches and practices used by the GCCR to increase transparency, rigor, and reproducibility.

Identification of an Amygdala-Thalamic Circuit That Acts as a Central Gain Mechanism in Taste Perceptions.

Peripheral sources of individual variation in taste intensity perception have been well described. The existence of a central source has been proposed but remains unexplored. Here we used functional magnetic resonance imaging in healthy human participants (20 women, 8 men) to evaluate the hypothesis that the amygdala exerts an inhibitory influence that affects the "gain" of the gustatory system during tasting. Consistent with the existence of a central gain mechanism (CGM), we found that central amygdala response was correlated with mean intensity ratings across multiple tastants. In addition, psychophysiological and dynamic causal modeling analyses revealed that the connection strength between inhibitory outputs from amygdala to medial dorsal and ventral posterior medial thalamus predicted individual differences in responsiveness to taste stimulation. These results imply that inhibitory inputs from the amygdala to the thalamus act as a CGM that influences taste intensity perception.SIGNIFICANCE STATEMENT Whether central circuits contribute to individual variation in taste intensity perception is unknown. Here we used functional magnetic resonance imaging in healthy human participants to identify an amygdala-thalamic circuit where network dynamics and connectivity strengths during tasting predict individual variation in taste intensity ratings. This finding implies that individual differences in taste intensity perception do not arise solely from variation in peripheral gustatory factors.

Recent Smell Loss Is the Best Predictor of COVID-19 Among Individuals With Recent Respiratory Symptoms.

In a preregistered, cross-sectional study, we investigated whether olfactory loss is a reliable predictor of COVID-19 using a crowdsourced questionnaire in 23 languages to assess symptoms in individuals self-reporting recent respiratory illness. We quantified changes in chemosensory abilities during the course of the respiratory illness using 0-100 visual analog scales (VAS) for participants reporting a positive (C19+; n = 4148) or negative (C19-; n = 546) COVID-19 laboratory test outcome. Logistic regression models identified univariate and multivariate predictors of COVID-19 status and post-COVID-19 olfactory recovery. Both C19+ and C19- groups exhibited smell loss, but it was significantly larger in C19+ participants (mean ± SD, C19+: -82.5 ± 27.2 points; C19-: -59.8 ± 37.7). Smell loss during illness was the best predictor of COVID-19 in both univariate and multivariate models (ROC AUC = 0.72). Additional variables provide negligible model improvement. VAS ratings of smell loss were more predictive than binary chemosensory yes/no-questions or other cardinal symptoms (e.g., fever). Olfactory recovery within 40 days of respiratory symptom onset was reported for ~50% of participants and was best predicted by time since respiratory symptom onset. We find that quantified smell loss is the best predictor of COVID-19 amongst those with symptoms of respiratory illness. To aid clinicians and contact tracers in identifying individuals with a high likelihood of having COVID-19, we propose a novel 0-10 scale to screen for recent olfactory loss, the ODoR-19. We find that numeric ratings ≤2 indicate high odds of symptomatic COVID-19 (4 < OR < 10). Once independently validated, this tool could be deployed when viral lab tests are impractical or unavailable.

More Than Smell-COVID-19 Is Associated With Severe Impairment of Smell, Taste, and Chemesthesis.

Recent anecdotal and scientific reports have provided evidence of a link between COVID-19 and chemosensory impairments, such as anosmia. However, these reports have downplayed or failed to distinguish potential effects on taste, ignored chemesthesis, and generally lacked quantitative measurements. Here, we report the development, implementation, and initial results of a multilingual, international questionnaire to assess self-reported quantity and quality of perception in 3 distinct chemosensory modalities (smell, taste, and chemesthesis) before and during COVID-19. In the first 11 days after questionnaire launch, 4039 participants (2913 women, 1118 men, and 8 others, aged 19-79) reported a COVID-19 diagnosis either via laboratory tests or clinical assessment. Importantly, smell, taste, and chemesthetic function were each significantly reduced compared to their status before the disease. Difference scores (maximum possible change ±100) revealed a mean reduction of smell (-79.7 ± 28.7, mean ± standard deviation), taste (-69.0 ± 32.6), and chemesthetic (-37.3 ± 36.2) function during COVID-19. Qualitative changes in olfactory ability (parosmia and phantosmia) were relatively rare and correlated with smell loss. Importantly, perceived nasal obstruction did not account for smell loss. Furthermore, chemosensory impairments were similar between participants in the laboratory test and clinical assessment groups. These results show that COVID-19-associated chemosensory impairment is not limited to smell but also affects taste and chemesthesis. The multimodal impact of COVID-19 and the lack of perceived nasal obstruction suggest that severe acute respiratory syndrome coronavirus strain 2 (SARS-CoV-2) infection may disrupt sensory-neural mechanisms.

Interactions of Lemon, Sucrose and Citric Acid in Enhancing Citrus, Sweet and Sour Flavors.

Flavorants such as lemon extract that activate olfactory receptors may also evoke or enhance flavor qualities such as sour and sweet that are typically considered gustatory. Similarly, flavorants such as sucrose and citric acid that activate gustatory receptors may enhance flavors such as citrus that are typically considered olfactory. Here, we ask how lemon extract, sucrose, and citric acid, presented separately and together, affect sweet, sour, and citrus flavors. We accomplished this by testing, in the same 12 subjects, lemon extract and sucrose (Experiment 1), lemon extract and citric acid (Experiment 2), and lemon extract, sucrose, and citric acid (Experiment 3). Results showed that both lemon extract and citric acid increased the ratings of citrus and sour intensity. Lemon extract did not affect sweet, but citric acid did, mainly in Experiment 3. Sucrose systematically increased only sweet intensity and modulated the effect of lemon extract on sour. The most robust multiquality effect was the enhancement of sour by lemon extract. These outcomes suggest, first, a role played by experience with the statistical associations of gustatory and olfactory flavorants and, second, that lemon flavor is complex, having citrus and sour qualities that may not be fully separable in perception.

Contextual Effects in Judgments of Taste Intensity: No Assimilation, Sometimes Contrast.

Judgments of taste intensity often show contextual contrast but not assimilation, even though both effects of stimulus context appear in other sense modalities, such as hearing. Four experiments used a paradigm that shifts the stimulus context within a test session in order to seek evidence of assimilation in judgments of the taste intensity of sucrose and, for comparison, the loudness of 500-Hz tones. Experiment 1 found no assimilation in taste using three response scales, magnitude estimation, labeled magnitude, and visual analog, but did find evidence of contrast. Experiments 2 and 3 found no clear evidence of either assimilation or contrast in taste, but found consistent evidence of assimilation in loudness. Experiment 4 found no assimilation in loudness, however, when the intervals between successive stimuli increased from about 6 to 30 s in order to match the interval used with sucrose in Experiments 1 to 3. Taken together, these findings suggest that the assimilation found in intensity judgments in other sensory modalities may not appear in taste perception because of the slower rates presenting of taste stimuli.

Basolateral amygdala response to food cues in the absence of hunger is associated with weight gain susceptibility.

In rodents, food-predictive cues elicit eating in the absence of hunger (Weingarten, 1983). This behavior is disrupted by the disconnection of amygdala pathways to the lateral hypothalamus (Petrovich et al., 2002). Whether this circuit contributes to long-term weight gain is unknown. Using fMRI in 32 healthy individuals, we demonstrate here that the amygdala response to the taste of a milkshake when sated but not hungry positively predicts weight change. This effect is independent of sex, initial BMI, and total circulating ghrelin levels, but it is only present in individuals who do not carry a copy of the A1 allele of the Taq1A polymorphism. In contrast, A1 allele carriers, who have decreased D2 receptor density (Blum et al., 1996), show a positive association between caudate response and weight change. Regardless of genotype, however, dynamic causal modeling supports unidirectional gustatory input from basolateral amygdala (BLA) to hypothalamus in sated subjects. This finding suggests that, as in rodents, external cues gain access to the homeostatic control circuits of the human hypothalamus via the amygdala. In contrast, during hunger, gustatory inputs enter the hypothalamus and drive bidirectional connectivity with the amygdala. These findings implicate the BLA-hypothalamic circuit in long-term weight change related to nonhomeostatic eating and provide compelling evidence that distinct brain mechanisms confer susceptibility to weight gain depending upon individual differences in dopamine signaling.

Weighing the evidence: Variance in brain responses to milkshake receipt is predictive of eating behavior.

Variations in brain responses to sensory stimuli are typically considered to lack information content and treated as "noise". Alternatively, variable response patterns may reflect the adjustment of biological parameters to external factors. We used functional magnetic resonance imaging in healthy non-dieting individuals to test whether intra-individual variation in brain response to the receipt of milkshake is associated with a range of behavioral and metabolic parameters. We found that, following a meal, high variability in nucleus accumbens (NAcc) response to milkshake is associated with higher body mass index, greater dietary disinhibition, more variable ad libitum food consumption, faster increases in plasma insulin, faster decreases in plasma glucose, and greater weight loss over 1year. Our results thus uncover a series of physiological parameters encrypted as variable responses in NAcc to food stimuli. They also suggest that variations in striatal activity regulate the activation of behavioral and metabolic responses to food availability.

Flavor Identification and Intensity: Effects of Stimulus Context.

Two experiments presented oral mixtures containing different proportions of the gustatory flavorant sucrose and an olfactory flavorant, either citral (Experiment 1) or lemon (Experiment 2). In 4 different sessions of each experiment, subjects identified each mixture as "mostly sugar" or "mostly citrus/lemon" or rated the perceived intensities of the sweet and citrus components. Different sessions also presented the mixtures in different contexts, with mixtures containing relatively high concentrations of sucrose or citral/lemon presented more often (skew sucrose or skew citral/lemon). As expected, in both experiments, varying stimulus context affected both identification and perceived intensity: Skewing to sucrose versus citral/lemon decreased the probability of identifying the stimuli as "mostly sugar" and reduced the ratings of sweet intensity relative to citrus intensity. Across both contextual conditions of both experiments, flavor identification associated closely with the ratio of the perceived sweet and citrus intensities. The results accord with a model, extrapolated from signal-detection theory, in which sensory events are represented as multisensory-multidimensional distributions in perceptual space. Changing stimulus context can shift the locations of the distributions relative to response criteria, Decision rules guide judgments based on both sensory events and criteria, these rules not necessarily being identical in tasks of identification and intensity rating.

Perceptual and Brain Response to Odors Is Associated with Body Mass Index and Postprandial Total Ghrelin Reactivity to a Meal.

Animal studies have shown that olfactory sensitivity is greater when fasted than when fed. However, human research has generated inconsistent results. One possible explanation for these conflicting findings is metabolic health. Many metabolic peptides, including ghrelin, are moderated by adiposity and influence olfaction and olfactory-guided behaviors. We tested whether the effect of a meal on the perceived intensity of suprathreshold chemosensory stimuli is influenced by body mass index and/or metabolic response to a meal. We found that overweight or obese (n = 13), but not healthy weight (n = 20) subjects perceived odors, but not flavored solutions, as more intense when hungry than when sated. This effect was correlated with reduced postprandial total ghrelin suppression (n = 23) and differential brain response to odors in the cerebellum, as measured with functional magnetic resonance imaging. In contrast, it was unrelated to circulating leptin, glucose, insulin, triglycerides, or free fatty acids; or to odor pleasantness or sniffing (n = 24). These findings demonstrate that the effect of a meal on suprathreshold odor intensity perception is associated with metabolic measures such as body weight and total ghrelin reactivity, supporting endocrine influences on olfactory perception.

Response Times to Gustatory-Olfactory Flavor Mixtures: Role of Congruence.

A mixture of perceptually congruent gustatory and olfactory flavorants (sucrose and citral) was previously shown to be detected faster than predicted by a model of probability summation that assumes stochastically independent processing of the individual gustatory and olfactory signals. This outcome suggests substantial integration of the signals. Does substantial integration also characterize responses to mixtures of incongruent flavorants? Here, we report simple response times (RTs) to detect brief pulses of 3 possible flavorants: monosodium glutamate, MSG (gustatory: "umami" quality), citral (olfactory: citrus quality), and a mixture of MSG and citral (gustatory-olfactory). Each stimulus (and, on a fraction of trials, water) was presented orally through a computer-operated, automated flow system, and subjects were instructed to press a button as soon as they detected any of the 3 non-water stimuli. Unlike responses previously found to the congruent mixture of sucrose and citral, responses here to the incongruent mixture of MSG and citral took significantly longer (RTs were greater) and showed lower detection rates than the values predicted by probability summation. This outcome suggests that the integration of gustatory and olfactory flavor signals is less extensive when the component flavors are perceptually incongruent rather than congruent, perhaps because incongruent flavors are less familiar.

Opposing relationships of BMI with BOLD and dopamine D2/3 receptor binding potential in the dorsal striatum.

Findings from clinical and preclinical studies converge to suggest that increased adiposity and/or exposure to a high fat diet are associated with alterations in dorsal striatal (DS) circuitry. In humans there is a reliable inverse relationship between body mass index (BMI) and response to palatable food consumption in the dorsal striatum (DS). Positron emission tomography (PET) studies also suggest altered DS dopamine type 2/3 receptor (D2R/D3R) availability in obesity; however, the direction of the association is unclear. It is also not clear whether dopamine receptor levels contribute to the lower blood oxygen level dependent (BOLD) response because PET studies have targeted the morbidly obese and, functional magnetic resonance imaging (fMRI) studies rarely include individuals with BMIs in this range. Therefore we examined whether the fMRI BOLD response in the DS to milkshake is associated with D2R/D3R availability measured with [(11) C]PHNO and PET in individuals with BMI ranging from healthy weight to moderately obese. Twenty-nine subjects participated in the fMRI study, 12 in the [(11) C]PHNO PET study, 8 of whom also completed the fMRI study. As predicted there was a significant negative association between DS BOLD response to milkshake and BMI. In contrast, BMI was positively associated with D2R/D3R availability. Dorsal striatal BOLD response was unrelated to D2R/D3R availability. Considered in the context of the larger literature our results suggest the existence of a non-linear relationship between D2R/D3R availability and BMI. Additionally, the altered BOLD responses to palatable food consumption observed in obesity are not clearly related to D2R/D3R receptor availability. Using [(11) C]PHNO and PET brain imaging techniques we show that body mass index was positively associated with D2R/D3R availability in the dorsal striatum, but that functional MR BOLD response was unrelated to D2R/D3R availability. These results suggest the existence of a nonlinear relationship between D2R/D3R availability and body mass index and that the altered BOLD responses to food consumption seen in obesity are not directly related to D2R/D3R availability.

Identification of gustatory-olfactory flavor mixtures: effects of linguistic labeling.

Two experiments, using different ranges and numbers of stimuli, examined how linguistic labels affect the identification of flavor mixtures containing different proportions of sucrose (gustatory flavorant) and citral (olfactory flavorant). Both experiments asked subjects to identify each stimulus as having either "mostly sugar" or "mostly citrus." In one condition, no labels preceded the flavor stimuli. In another condition, each flavor stimulus followed a label, either SUGAR or CITRUS, which, the subjects were informed, usually though not always named the stronger flavor component; that is, the labels were probabilistically valid. The results of both experiments showed that the labels systematically modified the identification responses: Subjects responded "sugar" or "citrus" more often when the flavor stimulus followed the corresponding label, SUGAR or CITRUS. But the labels hardly affected overall accuracy of identification. Accuracy was possibly limited, however, by both the confusability of the flavor stimuli per se and the way that confusability could limit the opportunity to discern the probabilistic associations between labels and individual flavor stimuli. We describe the results in terms of a decision-theoretic model, in which labels induce shifts in response criteria governing the identification responses, or possibly effect changes in the sensory representations of the flavorants themselves.

Midbrain response to milkshake correlates with ad libitum milkshake intake in the absence of hunger.

There is now widespread agreement that individual variation in the neural circuits representing the reinforcing properties of foods may be associated with risk for overeating and obesity. What is currently unknown is how and whether brain response to a food is related to immediate subsequent intake of that food. Here we used functional magnetic resonance imaging (fMRI) to test whether response to a palatable milkshake is associated with subsequent ad libitum milkshake consumption. We predicted that enhanced responses in key reward regions (insula, striatum, midbrain, medial orbitofrontal cortex) and decreased responses in regions implicated in self-control (lateral prefrontal and lateral orbitofrontal cortex) would be associated with greater intake. We found a significant positive association between response to milkshake in the periaqueductal gray region of the midbrain and ad libitum milkshake intake. Although strong bilateral insular responses were observed during consumption of the milkshake this response did not correlate with subsequent intake. The associations observed in the midbrain and orbitofrontal cortex were uninfluenced by ratings of hunger, which were near neutral. We conclude that midbrain response to a palatable food is related to eating in the absence of hunger.

Odor imagery but not perception drives risk for food cue reactivity and increased adiposity.

Mental imagery has been proposed to play a critical role in the amplification of cravings. Here we tested whether olfactory imagery drives food cue reactivity strength to promote adiposity in 45 healthy individuals. We measured odor perception, odor imagery ability, and food cue reactivity using self-report, perceptual testing, and neuroimaging. Adiposity was assessed at baseline and one year later. Brain responses to real and imagined odors were analyzed with univariate and multivariate decoding methods to identify pattern-based olfactory codes. We found that the accuracy of decoding imagined, but not real, odor quality correlated with a perceptual measure of odor imagery ability and with greater adiposity changes. This latter relationship was mediated by cue-potentiated craving and intake. Collectively, these findings establish odor imagery ability as a risk factor for weight gain and more specifically as a mechanism by which exposure to food cues promotes craving and overeating.

Odour-imagery ability is linked to food craving, intake, and adiposity change in humans.

It is well-known that food-cue reactivity (FCR) is positively associated with body mass index (BMI)1 and weight change2, but the mechanisms underlying these relationships are incompletely understood. One prominent theory of craving posits that the elaboration of a desired substance through sensory imagery intensifies cravings, thereby promoting consumption3. Olfaction is integral to food perception, yet the ability to imagine odours varies widely4. Here we test in a basic observational study whether this large variation in olfactory imagery drives FCR strength to promote adiposity in 45 adults (23 male). We define odour-imagery ability as the extent to which imagining an odour interferes with the detection of a weak incongruent odour (the 'interference effect'5). As predicted in our preregistration, the interference effect correlates with the neural decoding of imagined, but not real, odours. These perceptual and neural measures of odour imagery are in turn associated with FCR, defined by the rated craving intensity of liked foods and cue-potentiated intake. Finally, odour imagery exerts positive indirect effects on changes in BMI and body-fat percentage over one year via its influences on FCR. These findings establish odour imagery as a driver of FCR that in turn confers risk for weight gain.

Covid-19 affects taste independently of smell: results from a combined chemosensory home test and online survey from a global cohort (N=10,953).

People often confuse smell loss with taste loss, so it is unclear how much gustatory function is reduced in patients self-reporting taste loss. Our pre-registered cross-sectional study design included an online survey in 12 languages with instructions for self-administering chemosensory tests with ten household items. Between June 2020 and March 2021, 10,953 individuals participated. Of these, 3,356 self-reported a positive and 602 a negative COVID-19 diagnosis (COVID+ and COVID-, respectively); 1,267 were awaiting test results (COVID?). The rest reported no respiratory illness and were grouped by symptoms: sudden smell/taste changes (STC, N=4,445), other symptoms excluding smell or taste loss (OthS, N=832), and no symptoms (NoS, N=416). Taste, smell, and oral irritation intensities and self-assessed abilities were rated on visual analog scales. Compared to the NoS group, COVID+ was associated with a 21% reduction in taste (95% Confidence Interval (CI): 15-28%), 47% in smell (95%-CI: 37-56%), and 17% in oral irritation (95%-CI: 10-25%) intensity. In all groups, perceived intensity of smell (r=0.84), taste (r=0.68), and oral irritation (r=0.37) was correlated. Our findings suggest most reports of taste dysfunction with COVID-19 were genuine and not due to misinterpreting smell loss as taste loss (i.e., a classical taste-flavor confusion). Assessing smell and taste intensity of household items is a promising, cost-effective screening tool that complements self-reports and helps to disentangle taste loss from smell loss. However, it does not replace standardized validated psychophysical tests.

The anterior insular cortex represents breaches of taste identity expectation.

Despite the importance of breaches of taste identity expectation for survival, its neural correlate is unknown. We used fMRI in 16 women to examine brain response to expected and unexpected receipt of sweet taste and tasteless/odorless solutions. During expected trials (70%), subjects heard "sweet" or "tasteless" and received the liquid indicated by the cue. During unexpected trials (30%), subjects heard sweet but received tasteless or they heard tasteless but received sweet. After delivery, subjects indicated stimulus identity by pressing a button. Reaction time was faster and more accurate after valid cuing, indicating that the cues altered expectancy as intended. Tasting unexpected versus expected stimuli resulted in greater deactivation in fusiform gyri, possibly reflecting greater suppression of visual object regions when orienting to, and identifying, an unexpected taste. Significantly greater activation to unexpected versus expected stimuli occurred in areas related to taste (thalamus, anterior insula), reward [ventral striatum (VS), orbitofrontal cortex], and attention [anterior cingulate cortex, inferior frontal gyrus, intraparietal sulcus (IPS)]. We also observed an interaction between stimulus and expectation in the anterior insula (primary taste cortex). Here response was greater for unexpected versus expected sweet compared with unexpected versus expected tasteless, indicating that this region is preferentially sensitive to breaches of taste expectation. Connectivity analyses confirmed that expectation enhanced network interactions, with IPS and VS influencing insular responses. We conclude that unexpected oral stimulation results in suppression of visual cortex and upregulation of sensory, attention, and reward regions to support orientation, identification, and learning about salient stimuli.