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COVID-19 and Medical Nutrition – the story so far…

  By Rachel Sipaul RD    
 

With the COVID-19 pandemic taking hold, healthcare professionals have been challenged in ways we never expected. Similarly the role of medical nutrition is also being questioned, what are the nutritional priorities of patients with COVID-19 and does medical nutrition play a role? How do we integrate nutrition support into rehabilitation? 

To answer these questions we have seen a combined effort of clinical, academic, industry and government experts, working alongside professional organisations (e.g. BDA, BAPEN).  This pooled expertise and guidance will help us to understand the nutritional issues COVID-19 has raised and will continue to raise in the coming months.

 

Critical Illness

Initially there was an influx of critically ill patients into Intensive Care Units (ICU), with some patients staying in the ICU for many weeks. Critical care dietitians advised on feeding regimens, choosing the best enteral tube feed to meet energy and protein requirements in line with fluid restrictions. This however needed to be balanced with the complexity of feeding within proning (lying in face-down position) protocols, challenges of sedation, ventilation, renal and gastrointestinal impairment and limited feeding-access routes. Training was also required to work safely in an environment of reduced patient access and PPE protocols, and for non-ICU colleagues to assist with the increased workload. Publications early on, such as those from the BDA Critical Care Specialist Group, ESPEN, and other professional organisations across the world (HSE (ICU Dietitians), ASPEN, AusPEN) were valuable in sharing recommendations of best practice for critical care and beyond and these have continued to be updated.

ESPEN recommendations for critically ill patients with COVID-19

 

Beyond Critical Illness

As patients transitioned from ICU to hospital wards, it became clear that this stage was just as critical. Loss of muscle mass, loss of functional ability and poor dietary intakes were common and required nutrition support. As patients were weaned off enteral feeds, issues of dysphagia, poor appetite, taste changes, fatigue and emotional issues were cited. These all limit energy, protein and micronutrient intakes and patients often require nutritional strategies such as food fortification and oral nutritional supplements to boost their dietary intake. It became apparent that for some patients, COVID-19 was not an acute illness, it was, in fact going to require long-term support.

ESPEN Recommendations for COVID-19 Patients Requiring Oral Nutritional Support

 

Rehabilitation

And now we are in a position where large numbers of patients have been discharged from hospital. Rehabilitation protocols have been drafted and community patient-pathways proposed. The British Society of Rehabilitation Medicine, endorsed by the BDA, detailed the issues of nutritional compromise in community patients recovering from COVID-19. Understanding these nutritional concerns, means that strategies in the community to identify and support malnutrition are essential.

The NHS England reportAfter care needs of inpatients recovering from COVID-19also highlighted the importance of medical nutrition as one key part of rehabilitation

 

Practical COVID-19 nutrition-support pathways have been published such as the Malnutrition Pathway with screening tools such as ‘MUST’ (Malnutrition Universal Screening Tool) recommended for use to identify those at risk in this community-based group. Nutrition support may be required in the form of dietary advice and/or oral nutritional supplements and specialist support from a Dietitian to assist in those patients with complex nutritional needs.

It is also important to remember the large number of people recovering from COVID-19 who have never been admitted to hospital. While their illness may be less severe, it can still have a detrimental effect on their dietary intake and nutritional status. Particularly for the elderly, coupled with long periods of social isolation and difficulties in accessing food, this can lead to a poor dietary intake and weight loss. Screening for malnutrition should be considered essential when they first see a healthcare professional, and if required, a nutritional plan put in place to assist them.

The medical nutrition community has published an extensive array of guidance. This will continue to evolve as more research is completed and evidence becomes available. However what is clear now is that medical nutrition plays a crucial role in the management of, and recovery from COVID-19. It is essential nutrition support is integrated into every stage of a patient’s rehabilitation.